Factors affecting compliance with moving and handling policy: Student ...

Nurse Education in Practice 10 (2010) 96–100

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Factors affecting compliance with moving and handling policy: Student nurses’ views and experiences Jocelyn Cornish *, Anne Jones 1 Florence Nightingale School of Nursing and Midwifery, King’s College London, James Clerk Maxwell Building, 57, Waterloo Road, London SE1 8WA, United Kingdom

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Article history: Accepted 20 March 2009

Keywords: Moving and handling Manual handling Compliance Non-compliance

s u m m a r y The limited literature available suggests that there continues to be poor compliance by nurses with moving and handling regulations [Swain, J., Pufahl, E., Williamson, G., 2003. Do they practise what we teach? A survey of manual handling practice amongst student nurses. Journal of Clinical Nursing 12(2), 297–306; Jootun, D., MacInnes, A., 2005. Examining how well students use correct handling procedures. Nursing Times 101(4), 38–40; Smallwood, J., 2006. Patient handling: student nurses’ views. Learning in Health and Social Care 5(4), 208–219; Cornish, J., Jones, A., 2007. Evaluation of moving and handling training for pre-registration nurses and its application to practice. Nurse Education in Practice 7(3), 128–134]. This paper presents the final phase of a study in which student nurses’ reports of their experience in practice are drawn upon to identify possible reasons for a lack of compliance with moving and handling policy. Focus groups were conducted using a topic guide comprising themes generated from the previous two phases of this study; a questionnaire survey and unstructured interviews [Cornish, J., Jones, A., 2007. Evaluation of moving and handling training for pre-registration nurses and its application to practice. Nurse Education in Practice 7(3), 128–134]. Seventeen pre-registration students participated, representing adult, child and mental health branches from both Degree and Diploma programmes Examples of poor practice set the context for the students’ experiences. Factors affecting both compliance with poor practice or compliance with moving and handling regulations leading to good practice, are identified. Methods for the management of difficult moving and handling situations are also revealed. The study informs future developments in training and support mechanisms for students in practice. Ó 2009 Elsevier Ltd. All rights reserved.

Introduction The legal requirement for nurses to follow manual handling policy is incorporated within Health and Safety policy (Health and Safety Executive, 1992) and has the intention of preventing injuries to nursing staff through the provision of safe working environments and systems of work. These regulations also apply to student nurses but the concept of safe handling has a benefit to patients in that correct handling can enhance patient independence and comfort and reduce potential harm that could result from poor practice (Cornish and Jones, 2007). Literature review Despite the legal requirement to follow manual handling policy, a number of studies have provided evidence that students * Corresponding author. Tel.: +44 20 7848 3661. E-mail addresses: [email protected] (J. Cornish), [email protected] (A. Jones). 1 Tel.: +44 20 7848 3213; fax: +44 20 7848 3555. 1471-5953/$ - see front matter Ó 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.nepr.2009.03.020

have difficulty complying with such (Swain et al., 2003; Jootun and MacInnes, 2005; Kneafsey and Haigh, 2007; Smallwood, 2006; Cornish and Jones, 2007). Many of these studies relating to the student experience of this essential nursing role have been conducted to examine individual training programmes at specific institutions in the United Kingdom (UK), hence the increasing number of studies seemingly investigating the same concept. Differences in the studies relating to the student samples, their programme of education, year of training or experience, mean that they are not directly comparable although the concurrence of many of the findings supports the validity of the conclusions drawn to some extent. In presenting the data, the authors have identified some factors which contributed to the students’ experiences (Swain et al., 2003; Jootun and MacInnes, 2005; Kneafsey and Haigh, 2007) although none of the papers has explicitly commented on the context for compliance or non-compliance with policy that this paper seeks to address. Neither have these papers used a qualitative approach to identify specific factors that might provide alternative insight when developing solutions. There is no recent evidence of student experiences outside the UK available to inform this study; however the relevance of international

J. Cornish, A. Jones / Nurse Education in Practice 10 (2010) 96–100

literature would be questionable given the differences in nursing curricula and manual handling policy. The aim of this paper is to highlight factors that affect students’ compliance with moving and handling (M&H) policy. The term ‘moving and handling’ is favoured in this paper and is treated as synonymous with the term ‘manual handling’ which is still used in current policy.

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The moderator (JC) managed the group whilst a second researcher (AJ) kept field notes on the interactions between group members and managed the recording equipment. The focus group conversations were transcribed verbatim and were categorised according to content; key data are presented here to illustrate the main issues for students. Findings

Methods Research design Focus groups were conducted with 2nd year Degree and Diploma students to gather information on their experiences of moving and handling in the practice setting. This was the third phase of a mixed-method project to evaluate the M&H training in one Higher Education institution and its relevance to practice for pre-registration nursing students (Cornish and Jones, 2007). Sample, recruitment and ethics Prospective respondents were invited to participate in the project after the second year M&H theory update. Fifty-nine students expressed interest and were contacted by email to arrange the groups. Of these 17 (29%) were able to attend and 3 groups were arranged (n = 7, n = 5, n = 5, respectively). The students represented adult, mental health and child branches and gave their consent at the commencement of each group. All had completed M&H first year mandatory training and a variety of placements. Ethical clearance was secured from two Local Research Ethics Committees for the project as a whole. This was felt necessary as it was anticipated that the students might mention aspects of poor practice in the course of the focus group discussion which may have to be addressed. The students were asked to maintain the anonymity of the practice areas and staff involved in any incidents mentioned in the focus groups and information was provided on the measures to be taken to report poor practice. However, it was noted that such formal ethical clearance was not deemed necessary for some other studies in the literature as they were considered to be educational evaluations (Swain et al., 2003; Jootun and MacInnes, 2005). Data collection A topic guide (Fig. 1), informed by previous elements of the study, was used as a prompt for the discussion which sought information on: the students’ reasons for participation in the study; examples of their M&H experiences in practice, their reasons for compliance with a M&H task that they thought was wrong; factors affecting refusal of such a request and the circumstances in which they would take a risk (not follow M&H policy).

• • • • • • • •

Students participated on a voluntary basis because of a desire to contribute to improvements in the teaching of moving and handling, to confirm their experience with their peers, to report the reality of practice and to learn more about moving and handling as they did not think they knew enough. This paper illustrates the themes of poor practice and factors affecting compliance with both poor practice and moving and handling regulations (good practice) from this extensive dataset. Poor practice The following 8 categories of ‘poor practice’ arose from the students’reported experiences: Use of bedsheets to drag patients up the bed Non-completion of risk assessments No assessment of patients’ abilities Lifting/using condemned techniques Supporting the patient’s weight Poor communication Poor management of equipment Non-completion of equipment safety checks Three of these are presented below as examples: ‘the use of bedsheets to drag patients up the bed’; ‘lifting/using condemned techniques’ and ‘non-completion of equipment safety checks’. The first example of poor practice is the ‘use of bedsheets to drag a patient up the bed’ or from one surface to another in the case of a lateral transfer. This is an unacceptable practice which can cause harm to patients through shearing forces applied and increases the risk to staff in moving a load against resistance. Furthermore, bedsheets are not designed for this activity and are therefore not fit for purpose. ‘‘My first placement had it [equipment] all stacked up in the shelves [and it] didn’t work. Nobody ever went in there and nobody ever used the stuff in there and you just kind of got on with hoisting people up the bed using a sheet.” 05/04:2 The second example relates to ‘lifting/ using condemned techniques’ (Chell, 2003) to move patients: ‘‘I was asked to help a patient move from bed to chair and I knew that this person had been seen by the physiotherapist in the morn-

What is your motivation for participating in this study? Give an example of M&H in practice that you have experienced. Has anyone had a good experience? How many of you have been asked to participate in a manoeuvre you thought was wrong? Who has complied with such a request and why? Would you still comply with such a request? When did you first feel you could refuse such a request? Why? In what circumstances would you take a risk? Fig. 1. Topic guide.

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ing and they were perfectly able with one person to be encouraged to move themselves. The Health Care Assistant thought it was quicker and easier to lift. . .she said, ‘come on come and help me, put your arm under his arm’, and I said, ‘well I am really sorry but I feel that this is a dangerous procedure’ . . .” 15/03:7

Interestingly, this quotation indicates that having a more powerful status (being the staff nurse), may not work in a situation where the individual is outnumbered. The following example highlights the wish for more people to be in agreement with correct practice:

The third example relates to the non-completion of equipment safety checks. The following quotation illustrates the lack of available equipment and the impact of poor practice on the patient.

‘‘None of them were interested in getting a sliding sheet and doing it the correct way. So I found myself often with another person actually heaving him up the bed. But I felt in myself that that was just the totally wrong thing to do and I would have liked it if more people were all in agreement with. . . the correct practice” 17/03:4

‘‘I was sent to another ward to get their battery. It was a heavy duty hoist for a very large patient who was quite breathless and extremely anxious about getting into the hoist in the first place and then to be left suspended in midair while I legged it down the corridor to the next ward. But it is something that should have been checked.” 05/04:9 Factors affecting student compliance with poor practice In order to improve poor practice and provide adequate support for students it is important to understand why students comply with poor practice when they have been taught otherwise. Students feel relatively powerless in practice situations alongside other members of staff as this first quotation about ‘power relationships and perceived hierarchy’ suggests: ‘‘I would probably find it very difficult to say [as a student nurse] to someone, ‘no, I’m not doing that’, or, ‘should we do it this way?’ I’d feel like I was undermining their authority” 15/03:7 However, this second quotation relating to the ‘confidence of qualified staff in M&H skills’ suggests that students actively maintain the illusion that qualified staff know what they are doing and can guide the student: ‘‘the qualified staff may be not as confident in their skills either and if they are trying to teach a student they don’t want that highlighted by the student. And I think there might also be an issue of maybe them feeling slightly uncomfortable.” 05/04:6. Additional pressures on the student are created by the ‘need to fit in’ and to be accepted by the staff: ‘‘I don’t know, you want to be accepted, you want to be, if possible, even liked and you certainly do not want to be treated really badly, ignored and abused” 17/03:10. This student felt that they had been previously mistreated in a placement when they had tried to challenge poor practice. This next category titled ‘saving face’ was provided by a child branch student who hadn’t had to use their M&H skills much. In the situation they describe they are caring for a 15 year old boy with disabilities and were trying to help him from his wheelchair into the shower seat. Despite admitting that they didn’t know what they were doing, the important issue seems to be acting with confidence in order that the patient does not think this: ‘‘So he stood up and held the bar and I supported his weight and shifted him around and sat him down and that probably wasn’t very good practice... It was more to do with. . . him feeling I didn’t really know what I was doing.” 05/04:10. Compliance with poor practice was also reported as occurring when the students find themselves ‘in a minority’: ‘‘Where you have a group of three people and one person is really keen on using equipment and good practice and two people are, ‘let’s just get it done. . .’ then you are in the minority. Even staff nurses are in the minority and are kind of coerced into . . .” 17/03:4

Lastly, this conversation details the desire for the students to want to display consistent behaviour making them comply with poor practice because they had agreed to help and then found themselves in a situation from which they could not escape: MN ‘‘Yes, I’ve had to help move a patient from her bed to the chair with one other care assistant. Before I realised, the patient was already standing up and then fell over. The care assistant went off to do everything and I had to be there. I felt that I needed to be involved for patient care, if you see what I mean, although it was not the [right] way of doing it. JC ‘‘So, you said that the patient was standing before you realised what you were in the middle of. . . So did you feel pressurised to be involved?” MN ‘‘I was called over to assist so turned up to help and things were already happening so yes I felt pressured to be involved because the situation was already there.” 17/03:4. Some of the other findings from the focus groups highlighted the management strategies used by students in an attempt to remove themselves from such situations. They included: straight refusal; making a joke of the situation; avoiding staff with whom they felt they had to comply; getting someone else to help instead, prompting the use of appropriate equipment and reporting the situation to the ward manager. Factors affecting compliance with M&H regulations Data were also provided on the contextual factors which favoured compliance with M&H regulations and policy. The motivation in these situations was not to follow the regulations but rather the requirements of the workload or former injury, for example: ‘‘on the elderly ward it happens all the time, we are forever having to [move patients] so you are not going to take that risk” 05/04:4 ‘‘I have been involved in a certain situation; I thought to myself, I shouldn’t have done that. But having felt the strain on my lower back and having that [teaching] session this year, I have thought about myself and I have refused to take part or said, ‘we shouldn’t be doing it.” 15/03:1. The size of the patient or complexity of the task also prompted more careful planning of M&H: ‘‘My last placement was on a neurology ward and you had to do log rolls and that is when you can phone other wards and they will come because you have got a potential life-threatening hazard haven’t you? And if you don’t log roll properly with the right number of people then it is dangerous. . .” 15/03:11 ‘‘I’ve seen a full M&H assessment[in the patient’s notes] that 4 people need to do the move but perhaps that is because this person is highly dependent and has four carers at home constantly.” 17/03:2 M&H might also be more carefully considered when ward practices present opportunities to do so. In the next example, the ward


used a lot of agency staff; the bedside handover was introduced to aid continuity of care in the face of a transient workforce: ‘‘Often it wasn’t the person doing the handover that said, it was one of the others who said, ‘can this person mobilise?’ You’ve got things there, a stick or frame there so you can ask whether or not they can walk to the toilet. It makes you think about it because you’ve got the patient in front of you whilst on this other ward the handover was just in a side room so you don’t visually have the person there.” 15/03:6 Additionally, the following conversation suggests how equipment use may be encouraged when it is easy to use, staff are familiar with its function and purpose, and it is available: IC ‘‘I’ve very rarely seen a PAT slide used badly . . . but PAT slides seem to have been around for years and people know what to do with them whereas sliding sheets appear to be a slightly more recent idea and people don’t know how to use them” JC ‘‘What do you think?” IC ‘‘I think the PAT slide is very specific [for] moving from bed to bed. . .” SN ‘‘How else are you going to do it?” IC ‘‘Yes. It takes longer to get the right [sliding sheet] and position it properly and that kind of thing so it is kind of much more technical operation involved so people think do I really know what I am doing? Do I want to take the time to do all this? When I can just. . .‘‘(mimics dragging someone up the bed) 17/03:5. Discussion One of the most salutary conclusions drawn from these data is that students see poor practice performed and are actively encouraged to participate in incorrect practice by people who might be viewed as their role models. This is in contrast to the findings of Kneafsey (2007) who collected data from mentors relating to their support of students in patient handling. These mentors appeared not to recognise their contribution as a role model to students in these practices. As well as the potential risk to students from poor practice there is the additional concern that patients could be harmed, in direct contravention of the Nursing and Midwifery Council (2008) Code of professional conduct and the ethical principle of non-maleficence. It is important to investigate the reasons for and the influences on staff to flout these professional principles and specific legislation. This paper identifies some of these reasons and is therefore instrumental in the search for solutions. Staff should receive mandatory M&H training and yearly updates according to the regulations. It is unlikely that they would be taught physical lifting and condemned techniques such as those described by Chell (2003) since current training reinforces ‘no lifting’ policies in practice. It is therefore important to identify reasons for the continued use of outdated techniques and why staff are prepared to risk injuries to themselves and others in their execution as reported by participating students. Evidence from this student sample provides the example of patients being moved using bedsheets, which are inappropriate for patient handling. Their reports corroborate the most commonly mentioned experience of poor practice from students attending practical training updates and validates previous findings from a previous questionnaire survey (Cornish and Jones, 2007). In seeking an explanation it might be suggested that more appropriate M&H equipment is not available to assist patients to move and indeed the conclusion that equipment is lacking in clinical areas has been made from a number of studies (Swain et al., 2003; Smallwood, 2006; Cornish and Jones, 2007; Kneafsey and Haigh, 2007). However, evidence from the study reported here, and the work

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of Jootun and MacInnes (2005), suggests that appropriate equipment is often available but is simply not used. ‘Lifting’ or ‘dragging’ patients, rather than going to get appropriate equipment, is perceived as, ‘quicker and easier’ as the findings from this study suggest. Again this is a commonly reported rationale noted in the literature (Jootun and MacInnes, 2005; Cornish and Jones, 2007). It is clear from the phrases used in this rationale that some evaluation of the situation is made to be able to compare two solutions and assess one as being ‘quicker’ or ‘easier’. It could be assumed that there is an informal assessment of potential risk and benefits and a negation of risk in the lifting operation. A further example relates to the lack of risk assessment and gives insight to the fears and anxieties of patients who are asked to cooperate in using equipment. Within the scenario describing a patient being left hanging in a hoist whilst a new battery was found to get her down, there appears to have been no management of risk. Possible problems had not been anticipated nor solutions identified. An excuse given by staff is that patients don’t like the equipment and this is used as a rationale for manually lifting patients. Thus it can be concluded that the presence of poor role models with inappropriate attitudes towards risk management play a key part in the context of M&H, a condition exacerbated by a lack of, or inappropriate management of equipment. A further key finding relates to the powerlessness and vulnerability of students in the context of an established ward team (Jootun and MacInnes, 2005). The power of traditional hierarchies and the socialisation experience is identified in these data and it is interesting that such hierarchies are maintained even in the face of poor practice with the illusion of the skills of qualified staff being preserved. Students in this sample, felt unable to challenge poor practice, perhaps because it would undermine the hierarchical order, despite being cognisant of the risk to their health or potential patient harm; the consequences of such a challenge were obviously thought to outweigh these risks. The illusion is additionally maintained by the active performance of an act of confidence despite the acknowledgment of a lack of ability to perform the M&H task. In such contexts there appears to be safety in numbers and the availability of an ally can mean that a suggestion to follow regulations is carried through. It is noteworthy that having an authority status (e.g. being the staff nurse) may not be influential enough against a majority prepared to risk poor practice. Therefore, an adequate number of strong advocates of good practice may be the essential ingredient within the nursing team for a good practice outcome. It is clear that M&H comprises a complex interaction of interpersonal behaviours involving appraisal of: the situation, power relationships, risks, benefits, potential outcomes, possibilities of achieving the aim of care and attention to the consistency of own behaviour. These factors affected the M&H experiences of the participating students. This study has also identified factors that lead to good M&H practice. The nature of the patient care group and the work involved in patient handling has a clear influence on the chosen techniques. The student experiences presented here suggest that working with very heavy patients or those with complex disability needs or where there is the requirement for frequent handling focuses the mind towards safe handling measures. This concords with the findings of Daynard et al. (2001). Perhaps this is because there is little alternative for the use of older ‘lifting’ techniques with the informal assessment whether to use a ‘quick lift’ returning the verdict of less likely achievement of the aim or more hazardous consequences for the nursing team. The organisation of work is another important factor in compliance. The inclusion of a M&H assessment within patient handover

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information ensures it is a normal constituent of care provision rather than an extra component of work to be considered. The student’s example of the usefulness of a bedside handover in allowing visualisation of the patients’ needs is a good one. Lastly, it seems fundamental that operators must perceive equipment as a better solution to patient handling than former techniques if change is to occur. Perceived difficulties in accessing equipment or where the equipment is viewed as complicated to use is likely to result in it not being used. Attention to environmental conditions such as storage and inadequacies of space may be important here. This is a fundamental point for equipment designers and manufacturers to take on board but also has implications for managers in the organisation of space and work in the practice area.

practice; providing them with information to increase their awareness of factors affecting compliance with poor practice is one way to help them recognise difficult situations. Enhancing link lecturer support in the clinical setting, communicating strategies for managing difficult situations, developing confidence in equipment use through practise are useful approaches. The incorporation of ‘real-life’ scenarios into moving and handling updates can help students find practical solutions. The last area for development noted, getting the right equipment available seems to be one of the hardest solutions to achieve. The findings from this study at least provide some clues as to how it might be tackled.

Strengths and limitations of the study

Conflict of interest statement

This sample included adult, mental health and child branch students from both Degree and Diploma pre-registration programmes which was a strength for the variety of experiences that could be captured. However, it is important to consider that the participants were volunteers from one Higher Education Institution in the UK who were able to attend the focus groups. They may have had something specific to say about their experience which does not necessarily represent the experiences of those who did not volunteer or those who were unable to attend. Nevertheless, although it was not possible to verify their data, it is unlikely that they would have fabricated the specific examples they gave especially as the experiences they recounted concurred so strongly with those of other sample groups reported in the literature as previously mentioned. It could also be argued that the students may have had a tendency to report themselves as following correct procedure rather than complying with the incorrect practice of others. However, this has clearly not been the case in this study with some participants reflecting on their own involvement in poor practice in order to contribute to this research. It is possible that the focus group method was an advantage in the collection of these data and is therefore a worthy addition to research designs utilised in this field. Finally, although limited to the UK, these findings may be useful for international readers to draw upon in relation to the factors influencing compliance in their own specific practice. Conclusions for training and practice development An important outcome of this work is learning how to manage the gap between training and practice reality. Primarily it is important to be honest with students when discussing the realities of

None. Acknowledgements Our thanks to the students who participated and shared their views. References Chell, P., 2003. Moving and handling: implications of bad practice. Nursing and Residential Care 5 (6), 276–279. Cornish, J., Jones, A., 2007. Evaluation of moving and handling training for preregistration nurses and its application to practice. Nurse Education in Practice 7 (3), 128–134. Daynard, D., Yassi, A., Cooper, J., Tate, R., Norman, R., Wells, R., 2001. Biomechanical analysis of peak and cumulative spinal loads during simulated patienthandling activities: a substudy of a randomised controlled trial to prevent lift and transfer injury of health care workers. Applied Ergonomics 32 (3), 199– 214. Health and Safety Executive, 1992 (as amended). Manual Handling Operations Regulations. HSMO, London. Jootun, D., MacInnes, A., 2005. Examining how well students use correct handling procedures. Nursing Times 101 (4), 38–40. Kneafsey, R., 2007. Developing skills in safe patient handling: mentors’ views about their role in supporting student nurses. Nurse Education in Practice 7 (6), 365– 372. Kneafsey, R., Haigh, C., 2007. Learning safe patient handling skills: student nurse experiences of university and practice based education. Nurse Education Today 27 (8), 832–839. Nursing and Midwifery Council, 2008. The Code. Standards of conduct, performance and ethics for nurses and midwives. NMC, London. Smallwood, J., 2006. Patient handling: student nurses’ views. Learning in Health and Social Care 5 (4), 208–219. Swain, J., Pufahl, E., Williamson, G., 2003. Do they practise what we teach? A survey of manual handling practice amongst student nurses. Journal of Clinical Nursing 12 (2), 297–306.