Applied Nursing Research 39 (2018) 141–147

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Applied Nursing Research

journal homepage: www.elsevier.com/locate/apnr

Original article

Nurses and nursing assistants decision-making regarding use of safe patient T

handling and mobility technology: A qualitative study
⁎
Mary Louise Kanaskie, PhD, RN-BC, AOCNa, , Cynthia Snyder, MSN, RNb
a
Penn State Health Milton S. Hershey Medical Center, Hershey, PA, United States
b
Pediatric Endocrinology, Penn State Health, Children's Hospital, Hershey, PA, United States

A R T I C L E I N F O A B S T R A C T

Keywords: Aim: This study explored decision-making regarding use of safe patient handling and mobility (SPHM) tech-
Safe patient handling and mobility technology nology among registered nurses (RN) and nursing assistants (NA).
Qualitative research Background: Lifting injuries are common among healthcare workers. Despite development of standards for
Interprofessional collaboration SPHM, the introduction of regulation for monitoring access to SPHM technology, and implementation of edu-
Musculoskeletal injury among healthcare
cation programs and process improvements, threat of injury remains a concern. Although access to SPHM
workers
equipment is associated with decreased workplace injuries, access alone does not guarantee use. Questions
remain concerning how healthcare workers make decisions to use SPHM equipment, and how they weigh de-
cisions against personal safety.
Methods: A qualitative descriptive study was conducted. Data collection consisted of four 60 min focus groups.
Two focus groups consisted of all RNs (n = 14) and two consisted of all NAs (n = 11). Each focus group was
audiotaped and transcribed verbatim. Transcripts were coded, repeating concepts identified, and codes collapsed
into themes and subthemes.
Results: Qualitative analysis revealed three major themes: barriers to use, perceived risk, and coordination of
care. Barriers to use include subthemes of physical barriers, knowledge and skill, and unit culture. Perceived risk
includes patient risk and perceived risk to self. Coordination of care includes patient factors and characteristics,
assessment of patient needs and abilities, and interprofessional collaboration.
Conclusions: These findings provide new knowledge about the complexity of decision making among care
providers in the use of SPHM technology. Interprofessional team approaches to patient assessment and care are
important components of confident decision making in use of SPHM technology.

Musculoskeletal injuries among nurses and healthcare professionals 1. Background

related to patient handling activities are a growing concern (Carpenter,
2017; Fitzpatrick, 2014; National Institute for Occupational Safety and
Health, 2016). In the last decade, efforts to address this health risk have
led to the development of standards for safe patient handling and mo-
bility (SPHM), implementation of federal regulations for monitoring
access to SPHM technology, and implementation of educational pro-
grams in pre-licensure and employment settings. Despite these efforts,
the American Nurses Association (ANA) (2016) Health Risk Appraisal
revealed only half of the respondents consistently use the SPHM tech-
nology even when it is accessible. Furthermore, high rates of injuries
result in days away from work and are a costly concern for individuals
and employers alike (Przybysz & Levin, 2017). Despite high injury
rates, little is known about the factors that influence healthcare
workers' decisions to use SPHM technology.
The United States Bureau of Labor Statistics (2015) reports that
hospital staff when compared to other industries rank high related to
the rate of injuries resulting in days away from work. Although there
has been improvement in rate of injuries in recent years, nursing as-
sistants ranked fourth in 2015 (United States Department of Labor
Bureau of Labor Statistics, 2015). Importantly, the occurrence of mus-
culoskeletal injuries among healthcare workers may be compounded by
an aging nursing workforce, staffing shortages, and the growing pro-
blem of obesity in the general population (Kuehn, 2013; Ribeiro,
Serranheia, & Loureiro, 2017).
In 2013, ANA published Safe Patient Handling and Mobility -
Interprofessional National Standards across the Care Continuum with the
goal of preventing or minimizing healthcare worker and healthcare
recipient injuries (ANA, 2013). Implementation of the ANA standards,

⁎
Corresponding author at: MC-H102, Penn State Health Milton S. Hershey Medical Center, PO Box 850, Hershey, PA 17033, United States.
E-mail address: mkanaskie@hmc.psu.edu (M.L. Kanaskie).

https://doi.org/10.1016/j.apnr.2017.11.006
Received 11 August 2017; Received in revised form 19 October 2017; Accepted 2 November 2017
0897-1897/ © 2017 Elsevier Inc. All rights reserved.
M.L. Kanaskie, C. Snyder
which address employer and healthcare worker responsibilities, is an
important goal in all healthcare settings. Additionally, in an effort to
safeguard compliance with employment standards, the Occupational
Safety and Health Administration (OSHA) developed a monitoring
program for integration of safety practices in healthcare institutions
(OSHA, 2013).
Strides taken to implement the ANA standards are multifaceted and
include ergonomic programs, no lifting policies, and purchase of state
of the art technology to assist with patient lifting and mobility. These
programs demonstrate effectiveness in reducing employee injury rates
related to manual lifting, reduced lost work days, and reduced workers
compensation costs (Karg & Kapellusch, 2012; Lahiri, Latif, & Punnett,
2013; Lee, Faucet, Gillen, & Kause, 2013; Mayeda-Letourneau, 2013;
Park, Bushnell, Bailer, Collins, & Stayner, 2009; Powell-Cope et al.,
2014). While this data is useful, it may not be adequate in under-
standing the full scope of the problem. Musculoskeletal injuries may not
always be traced to one event; rather, they may be an accumulation of
exposures to extreme postures sustained over time and repetitive in
nature (Ribeiro et al., 2017). Although improvements in employee in-
jury rates may occur in the short term (up to 1.5 years post-im-
plementation), reports indicate these improvements do not demonstrate
long-term (1.5–2.5 years post-implementation) sustainability without
additional safeguards (Martin, Harvey, Culvenor, & Payne, 2009; Theis
& Finkelstein, 2014).
Evaluation of SPHM programs has led to identification of barriers to
use of SPHM technology which include availability of lift equipment,
education on the use of SPHM equipment, and ample time to complete
assigned tasks (Gucer, Gaitens, Oliver, & McDiarmid, 2013). Employee
motivation, commitment by management, and patient-related factors
(Karg & Kapellusch, 2012) have also been identified as barriers to use.
Many safe patient handling programs have addressed these barriers
leading to innovative approaches such as utilization of peer leaders,
staff competency training, and nursing and managerial support (D'Arcy,
Sasai, & Stearns, 2011; Powell-Cope et al., 2014; Przybysz & Levin,
2017; Schoenfisch, Pompeii, et al., 2011).
Despite all of these efforts to develop effective SPHM programs,
nurses report inconsistent use of SPHM technology even with access to
equipment (ANA, 2016's Health Risk Appraisal Findings). Under-
standing the dynamics of decision-making related to use of SPHM
technology is important for successful implementation of safety stan-
dards and for long term health of the nursing workforce. Questions
remain concerning how decisions are made to use SPHM technology
and how nurses and nursing assistants weigh decisions against personal
safety. The aim of this study was to explore factors which influence
decision-making regarding the use of SPHM technology among regis-
tered nurses (RN) and nursing assistants (NA).
2. Method
A qualitative descriptive study was conducted to understand RNs
and NAs decision making regarding use of SPHM technology. The study
was conducted at a 550 bed quaternary care academic medical center.
Institutional Review Board (IRB) approval was obtained and informed
consent was obtained from participants prior to participation, in ac-
cordance with IRB procedures.
Qualitative descriptive studies “offer a comprehensive summary of
an event in the everyday terms of those events” (Sandelowski, 2000,
p.336). Focus group methods were chosen for data collection due to the
characteristic group interaction and non-verbal communication that
reveals beliefs, attitudes and feelings about a topic (Krueger & Casey,
2015). Four 60 minute face-to-face focus groups were conducted over a
four month time period. A semi-structured interview approach was used
and an interview guide was developed to initiate discussion. A team of
three researchers, who also served as moderators, conducted the in-
terviews with two moderators present at each focus group. Focus
groups were audiotaped and transcribed verbatim for accuracy. Field
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Applied Nursing Research 39 (2018) 141–147
notes and moderators' reflections were recorded following each focus
group. Analysis, conducted by the research team, began immediately
following review of the first focus group transcript. In qualitative re-
search, data analysis often begins while researchers are still collecting
data (Merriam, 2009). Researchers originally set out to conduct three
focus groups; however, to ensure data saturation, a fourth focus group
was conducted which produced re-emergence of existing themes.
3. Sample
A purposive sample of volunteers was selected from nursing staff of
a specialty adult intensive care unit (ICU) and one medical-surgical unit
designated as a bariatric specialty unit with access to portable and
overhead mechanical lift equipment. RNs from each of the two selected
units were invited to participate with their unit peers creating homo-
geneity of groups based on role and work unit. In addition, NAs from
across the institution were invited to participate in one of two focus
groups, representing each of the two selected units and additional
medical-surgical units. Inclusion criteria included: direct care RN and
NA on adult medical surgical inpatient unit or adult specialty ICU.
Nurses in leadership roles were excluded from the study (clinical head
nurses, nurse managers, advanced practice nurses, and clinical nurse
educators). Study participants (n = 25) were distributed among four
focus groups: Two focus groups consisted of all RNs (n = 14) and two
consisted of all NAs (n = 11), with six to eight participants in each
focus group. Participant demographic data is presented in Table 1.
4. Data analysis and management
Transcripts, typed verbatim, included numbers assigned to identify
speaker participation. Analysis by speaker numbers indicated full par-
ticipation of group members. The three member research team was led
by a doctorally prepared nurse with experience in qualitative research
methods. Focus group transcripts were carefully read with concepts and
key responses highlighted. Individual analyses were discussed followed
by group consensus of key concepts and responses. The second phase of
coding included identification of repeating concepts. Codes were col-
lapsed into themes and subthemes. Themes were analyzed and com-
parisons discussed until census was reached. Potential researcher bias
was addressed at all stages of the study including study design, data
collection, and analysis. Researchers challenged one another's as-
sumptions and documented a decision trail for all stages of analysis.
Table 1
Participant demographic characteristics (n = 25).
RN (14) NA (11)
Age Average 39.3 35.5
Range 27–49 21–60
Years in practice Average 4.7 9.2
Range 1–25 3–26
RN educational preparation
Associate degree n = 6 (43%)
Baccalaureate degree n = 8 (57%)
Learned to use mechanical lift equipment1
School n = 14 (56%)
On-the-job training (Hospital) n = 17 (68%)
On-the-job training (LTC)a n = 11 (44%)
1
Includes responses from both RNs and NAs (n = 25). Individuals may have
indicated more than one answer.
a
LTC - Long Term Care Facility.
M.L. Kanaskie, C. Snyder
5. Findings
Qualitative analysis revealed three major themes: barriers to use,
perceived risk, and coordination of care. Each of these themes is further
explained by subthemes detailed in Fig. 1 and described through ex-
emplars below.
5.1. Barriers to use
Barriers to use included subthemes of physical barriers, knowledge
and skill, and unit culture.
5.1.1. Physical barriers
Participants identified physical barriers as a major deterrent to
using lift equipment. Physical barriers include inability to access
equipment, limitation in storage space, and inadequate space to man-
euver equipment into patient rooms. The perceived level of difficulty in
locating equipment accessories such as cords and pads was viewed as an
inconvenience that influenced decisions to not use lift equipment. Space
limitations and equipment incompatibility were described as major
challenges. The physical layout of some hospital units further limits
maneuverability of equipment.
… the only way for us to get this into the room is to move the recliner
chair all the way to the window, and we get sandwiched in…It's just that
tight. It is so tight. Inches. And the lifts are really big. The legs go in and
out … they're long. It's tricky. So you gotta be creative. Trash can goes in
the bathroom. Bedside table goes in the bathroom.
In addition, chair and bed heights vary creating additional chal-
lenges. The following discussion among three participants (P1, P2, and
P3) further illustrates this point:
P3: Actually sometimes PT [physical therapy] gets them out into the
chair and we have to get them back into the bed and it's not always as
easy as it was when they put them out into the chair.
P1: Right because the bed can be adjusted to a certain height. When
you're in the chair they're low you can't get around them as easy. A lot of
the chairs don't lock very well.
P2: You can't pull around them. (Quiet).
Since time can be described as a physical dimension it is described
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Applied Nursing Research 39 (2018) 141–147
Fig. 1. Themes and sub-themes of the factors influencing
decision-making regarding the use of SPHM technology
among RNs and NAs.
within this subtheme. Time was a perceived barrier in RN and NA de-
cisions to use lift equipment. Time was needed to prepare the patient,
obtain the equipment, assess the patient's ability, and carry-out the
actual procedure. The situation was compounded by difficulty in
finding another staff member to assist subsequently leading RNs and
NAs to provide care independently.
…once again that takes time. You've got to roll them, put that sheet under
them, pull them up, where you could have [manually lifted] them. Again
you're risking injury but it could have took two minutes to pull them up
versus 10 minutes to put them on that sheet and up. Time, once again.
One participant challenged the belief about time reflecting on the
concept this way:
I wonder sometimes…what the time difference actually is. Like is it a
perception that it's going to take me more time to get the lift?… How
much more time would it really take?… Do I really have time to get the
lift… Is it really an extra 90 seconds when in my mind it is feels like 10
minutes.
5.1.2. Knowledge and skill
Participants described lack of sufficient training in using lift
equipment. This sentiment was expressed even though the institution
provides training on newly purchased devices and new employees learn
about the devices during orientation. Without consistent use or ongoing
practice, RNs and NAs described decreased confidence in their skills
which they attributed to the subsequent decline in their use of SPHM
equipment.
NA: I think a lot of the nurses are not up to date on what kind of
equipment we have… and we had orientation, everybody did, but I think
it needs to be more consistent like every 3 months. And it seems re-
dundant but you just do. You just need to refresh your memory, you don't
use something for a while you forget how to use it.
RN: … There's such a gap between the times I use it. When I use it, it's
usually a good experience… I'm not comfortable (with it) because I don't
use it all the time…and then I lose my confidence.
Both RNs and NAs perceived that NAs possess more expertise with
the lift devices than RNs and attributed this to experience that many
NAs acquire from previous employment often in long term care facil-
ities. “…when we get the lifts out the nurses are like ‘Oh no, no, you guys do
M.L. Kanaskie, C. Snyder
it. You guys know what you're doing.’” NA's core responsibility of pro-
viding direct physical care was cited by both RNs and NAs as a potential
reason for this difference. Both RNs and NAs remarked that the frequent
need for RNs to attend to other patient priorities made it more likely
they were unavailable to assist with patient handling and mobility ac-
tivities.
5.1.3. Unit culture
Practices for delivering basic nursing care may vary from unit to
unit within an institution and from shift to shift within one unit. The
term “unit culture” here refers to the accepted practices related to the
delivery of basic nursing care and includes assisting patients with
meals, bathing, and other activities of daily living. The impact of unit
culture is illustrated in the staff narratives describing the organization
of care in its totality and how basic nursing care is carried out. One NA
describes it this way:
(We) try to get all of our (patients) up for breakfast or at least in the
morning. If breakfast comes on time, there's no time. But we do our baths
in the morning so we're getting people up. The nurses want to see their
bottom and their skin and stuff so I usually ask my nurses… We're trying
to coordinate our care together…
Another NA describes unit practice norms about the routine use of
SPHM equipment and how they influence new staff's transition to the
unit and institution:
The new grads coming in, if they see us not using them [SPHM equip-
ment] they're inclined then to learn to do without. Our unit has a bunch
of new people coming from outside hospitals or other facilities and you
come in and you didn't see anyone using it. So then we just adapted to
that way. [New NAs] they'll come in and I'll follow their lead and do
what they're doing.
5.2. Perceived risk
Perceived risk emerged as a factor in decision-making related to use
of mechanical lift devices. The two subthemes associated with per-
ceived risk were patient risk and self-risk.
5.2.1. Patient risk
Nurses identified general characteristics of patients at risk for falls
while ambulating. Those patients who can ambulate with assistance
presented unique challenges. As participants described, some patients
can ambulate to a chair with assistance; however, patient fatigue often
requires the use of an assist device in getting back to bed. Without
proper pre-planning, using the assist device correctly may be difficult.
…if (the patient) can go to the chair with one or two (of us) assisting…
back to bed, they need the lift…now they're so tired and their legs are like
jello.
… [the patient had enough] strength that we were able to stand and pivot
and she really didn't like being in bed… at start of my shift we got her out
of bed and into the chair with just a standard pivot. …I knew by the end
of the day we were probably going to have to use a lift…Sure enough, 6
o'clock at night, she decided she wanted to get back into bed … she
couldn't stand and pivot and I had to get three people to help me get her
back in bed.
So getting up to that chair you use a lot of energy getting up and sitting up
is usually even more energy. So by the time it's time to go back to bed,
now you have no energy to help do anything.
In addition, RNs and NAs explained that patient and family mem-
bers' fears also contributed to the decision about whether to use SPHM
equipment. Patient's fear of falling from the lift equipment and fear
related to lack of confidence in the healthcare provider's expertise with
the equipment were examples provided. One participant explained that
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patients experiencing a previous fall of any kind are often fearful.
(Sometimes they'll say) No. No. No. I'm scared. That's why commu-
nication is the important thing. We have to tell them and guide them …
step by step just to calm them down.
In addition, participants revealed that patients and families some-
times view use of a lift device as a negative measure or insult related to
patient size and weight. Several participants described assuring patients
and families about the use of lift and other assist devices to promote
patient and staff safety.
5.2.2. Self-risk
Concern for personal health was described by some as a motivator
for using SPHM devices. One NA described how past injuries influence
her decisions:
…I use a lift. I don't like to do it [manual lifting] because I have back
problems…I don't want to hurt my back… I would rather not take that
chance. I've hurt my back two years ago and I was like out of commission
for a couple days and it wasn't anything that really happened, it was just
all of a sudden, I was sitting in a chair doing a one to one and I sat too
long, didn't get up, and I bent over to tie my shoe and it was like – the
chiropractor said it's just a buildup of everything.
Past injury experiences were not always a determinant to use safe
handling practices. The following dialogue among three NAs (P1, P2,
and P3) further demonstrates this thinking:
P1: Oftentimes after I've done something that I probably shouldn't have
done like pulled my back or whatever, hoisting by myself or doing
whatever, I think well you know in ten years I probably won't be able to
do this. So maybe I should take care of myself now. But it's usually after
the fact. It's something I should probably start thinking before I do this,
like pulling a patient up by myself.
P2: I don't consider (my health) at all.
P3: Yeah I know for me usually it's easier for me to quick pick them up
and put them in a chair then just grab something [equipment] so I don't
really think about it.
Some RNs and NAs recognized the potential risks to self but in the
moment described choosing the path that seemed fastest and did not
require peer assistance:
Sometimes you're in a hurry. I just had a (patient) and I said “pull on me
and let me get the pillow down behind your shoulders.” Thinking well
surely it wouldn't be that much of a strain. And even just that little (bit),
and it was more like a gesture, and I didn't hurt it but I felt (I could have)
– so yeah I'm afraid. I can't afford a back injury.
Participants described awareness of their own age and physical
strength as well as their peers. The following dialogue among six RN
participants (P) demonstrates self-awareness of personal risk:
P8: I don't have that ability. I'm short and I can't even pull somebody up
to the top of my bed by myself so. I can't. I need help every time or
otherwise I'll be like half on the bed pulling someone and I'm like what the
heck.
P2: Yeah usually I can't turn somebody on the bed by pulling. I have to
ask for help.
P6: (quiet) I'm older.
P3: See, I think age has a lot to do with it!
P5: It's wisdom.
P6: I'm more inclined to know that I'm older, unlike before. I would ask
the pervious nurse hey … sometimes I still do that but not like, I'm really
conscious… so if I know like…
M.L. Kanaskie, C. Snyder
P4: Well, I need a knee replacement but I'm too young. I'm more mindful,
like I won't go pick somebody up just cuz I don't know if my knee will
support me…and so I usually get help with that.
Recognition of patient sedation and inability to assist in post pro-
cedure transfers and lifts, led to an awareness of personal risk not de-
scribed in other routine care activities. Reflection on personal risk in-
cluded analysis of co-workers physical abilities to fully participate in a
manual lift or assistance with mobility activities. One NA described
how partnering with an individual who has minimal strength places one
at a greater risk of injury.
We had to get a patient back into bed from the bedside commode, and the
nurse was like help me get him back. Well the nurse was like really little
and not really strong…. You know I was expecting a little help here and
we stand and pivoted and [the patient is] like hanging on the end of the
bed. I'm killing my back and I'm like ‘go get a male nurse’ and we're
yelling for help. So you know you don't always – it's not always pre-
dictable.
Male participants reported being called upon frequently to assist in
all patient handling and mobility situations especially when manual
lifting was employed. One male stated:
I don't mind, I'm more than happy to help. It's just part of helping out. I
wouldn't want my coworker to get injured because I was not willing to
help.
5.3. Coordination of care
Coordination of care emerged as an important theme in under-
standing decision-making related to patient mobilization. Subthemes
include patient related characteristics, assessment of patient needs and
abilities, and inter-professional coordination of care.
5.3.1. Patient related characteristics
Participants described patient characteristics or factors that de-
termine choice of SPHM equipment. These include individual needs of
the patient related to diagnosis, physical and cognitive abilities, pre-
existing conditions, and de-conditioning since admission.
The following dialogue between two RNs (P2 and P4) demonstrates
this point:
P2: Unless they have some retention issues then straight cath them first
then you can put them in the chair and that way they're okay for a while.
And then maybe 3–4 hours and you can put them back in the bed.
P4: And I think the flow of your day has a lot to do with it too. Right like
if you have a critical patient, your other patient's critical, you're going to
be with them and you don't have the time or the manpower to get
somebody out of bed who doesn't have to do it in a lift.
P2: Plus it's hard for a confused patient and they can't bear weight and if
you put them in a chair because then it might be a fall hazard for them…
whereas if they're in the bed. It has alarms. Although they can put the
alarms in too but you aren't gonna always be there to check on them.
Patient motivation to be out of bed or to ambulate was also iden-
tified as a factor which could be a deterrent to early mobilization and
could impact whether a mechanical lift device was employed.
Of our 12 patients, 9 of them are geriatric… some can walk with their
walkers, they can do what they need to do but we have a few of them that
are bed bound right now because we're waiting for PT to come (to
evaluate). Their level of skill (needs) has changed from when they left
their home. There are a lot of different factors that go into getting them
up.
…factor in their motivation…they can move but they choose not to…
they have good strength but they refuse to participate…you know you
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assessed them, and they know they could, but their motivation is not
there.
5.3.2. Assessment of patient needs and abilities
Lack of confidence concerning assessment of patient ability was
described by both RNs and NAs. Lack of confidence in assessment was
sometimes described as skill in making the proper assessment. At other
times, lack of confidence was related to the continual changes in the
patient's ability to ambulate. Patient ability can change from pre-ad-
mission to hospitalization and can change on a daily basis.
If you're the primary nurse, you should know your patient, but it's not
always [true]. You might think they have some strength and they don't.
In addition, RNs and NAs commented that they rely on therapy staff
(physical and occupational therapy) to weigh in on the decision related
to patient abilities prior to attempting to mobilize the patient. Some
RNs expressed reluctance to perform an independent assessment “at
least for the first initial assessment” without the therapist's input.
Since patient ability can change within hours, some RNs feared the
patient falling because of an error in judgement. The following dialogue
between two RNs (P1 and P4) expresses the nurse's fear of the patient
falling during an attempt to ambulate:
P4: I don't think it's a problem assessing, I think it's more fear of the
patient falling.
P1: You just feel better with their [physical and occupational therapists]
professional input.
P4: Right. I mean, yeah, of course I can assess too to some limited extent,
but sometimes I feel better having their blessing.
5.3.3. Interprofessional collaboration
The need for inter-professional collaboration in care planning was a
recurring subtheme. As seen in the previous subtheme, assessment of
patient abilities was viewed as an important need for collaboration. In
addition, the need for inter-professional collaboration was based on
reliance on the expertise of the physical and occupational therapy staff
to assist with determination of chosen method for ambulation and
whether to use SPHM equipment. The following dialogue among two
RNs (P3 and P5) illustrates this point:
P3: I think for me to use it [SPHM equipment] depends…I'm more likely
to use it if physical therapy comes in and they think that it needs to be
used. Then I'll use it with them, or if another staff member that's used to
using them more frequently suggests it and uses it with me. I'm not usually
inclined to do it on my own for some reason.
P3: I just think they are more expert at deciding whether that patient can
safely stand or not. I don't want that responsibility if the patient falls or
collapses on me.
P5: They test their strength and we might think that leg is able to, that one
leg is able to hold that weight to stand up, but you know they test their
strength and know better/more than we do.
P3: And they know how to tell them to move better than I do. I'm more of
a helper. I wanna do everything for the patient, which the lift is supposed
to be doing that more so than me I think.
Although valuing interprofessional collaboration with therapy staff,
RNs described difficulty in coordinating care due to perceived limited
availability of therapy services. In addition, RNs and NAs described
situations where they were working alongside therapy staff but not
always planning care together.
Usually for us it's more the nurse and the NA making that decision
knowing that they either use the lift at home or they're gonna need that
much help because we don't have time to wait for the therapy consult to
M.L. Kanaskie, C. Snyder
get them.
When therapy comes to our floor, they just get the person up. Yeah
they're one assist. You guys can get them back to bed then. And we go to
get them back in bed and we're like oh no it's not a one assist. Go get the
lift. And then it's trial and error.
[The patient is] in the chair, exactly and we're trying to get them back in
bed… Therapy's not coming to help get this person back in bed. I don't
know, did they really stand up and get in or did therapy just kind of get
them into the chair, I don't know.
6. Discussion
Findings of this study provide new information about decision-
making regarding SPHM technology among RNs and NAs. The current
study identifies the importance of interprofessional collaboration with
physical and occupational therapy staff in assessment and care planning
as it relates to the safe practice of patient handling and mobility. This
concept has not yet been identified as a factor in literature describing
SPHM best practices. Reports from the current study show a reluctance
of some RNs to make decisions about patient abilities independent of
the occupational therapists and physical therapists. The findings of this
study point to the importance of healthcare professionals' teamwork in
planning and coordination of care that is patient centered. Taylor, Sims,
and Haines (2014) reported similar findings related to decision-making
among care staff in nursing homes. They found that inexperienced care
staff needed support of more experienced staff during mobility care and
concluded that collaborative approaches are important measures to
increase staff confidence. In acute care settings, absence of inter-
professional collaboration between RNs and occupational and physical
therapy staff may lead to delays in instituting therapeutic plans for
mobility leading to negative patient outcomes and increased length of
stay.
As seen in the current study, assessment of patient abilities and
determination of appropriate interventions is multifaceted. The com-
plexity of the patient assessment and subsequent plan of care were
described in this study as dependent upon patient condition and subject
to change on a daily basis. ANA Safe Patient Handling and Mobility -
Interprofessional National Standards across the Care Continuum (2013)
address patient-centered assessment and support implementation of
standard assessment tools (ANA, 2013). The benefit of nurse-driven
assessment tools is described in the literature (Boynton, Kelly, & Perez,
2014; Kalisch, Dabney, & Lee, 2013; Schoenfisch, Myers, Pompeii, &
Lipscomb, 2011; Stevens, Rees, Lamb, & Dalsing, 2013) but studies are
needed to evaluate the effectiveness of these tools and intervention
outcomes.
Results of this study show that RNs described having inadequate
knowledge and skill in use of SPHM equipment and both RNs and NAs
identified the need for more activities focusing on review of basic
concepts and skills. While some knowledge and skill deficits were
known, the degree and scope of the skills training needs were made
visible. The findings of this study support the literature describing
training and efficiency as barriers in adoption and implementation of
safe patient handling practices (Aslam, Davis, Feldman, & Martin, 2015;
Olkowski & Stolfi, 2014; Schoenfisch, Myers, et al., 2011). Theis and
Finkelstein (2014) reported reduction in injury following training but
noted that the rates were not sustained long term (greater than
1.5 years). They hypothesized that retraining can serve to remind staff
of SPHM practices and provide cost savings related to sustained low
injury rates. Review of current practices related to initial and ongoing
education and competency of staff is warranted.
Identification of barriers to use of SPHM technology, beyond simple
access, are important to implementation and sustainability of SPHM
programs (Stevens et al., 2013). The findings of this study demonstrate
the challenges of using new technology in the physical space
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Applied Nursing Research 39 (2018) 141–147
characteristic of many older facilities. These structural challenges are
not easily remedied and create obstacles that may jeopardize patient
and staff safety. To our knowledge, barriers to use of SPHM equipment
created by physical space, aside from storage capacity, have not been
noted in the literature. This study provides descriptions of how physical
space limitations can influence RNs and NAs decisions about patient
care delivery using SPHM technology.
Participants in this study described concerns for patient risk which
influenced their decisions about using SPHM technology. Patient risk
associated with the use of SPHM equipment was reported in a national
survey of U.S. Department of Veteran's Affairs medical centers revealing
both skin and fall related adverse patient events associated with safe
patient handling (Elnitsky, Lind, Rugs, & Powell-Cope, 2014). Re-
commendations to prevent patient injury are consistent with the pre-
vious discussion and include nursing assessments, access to equipment
at point of care, staffing support systems, and patient and family
communication (Elnitsky et al., 2014).
It is important to note that little has been reported about healthcare
workers perception of self-risk and decision making to use SPHM
equipment. RNs and NAs in this study described concern for self-risk
when previous injury or ongoing job-related physical ailments were
present. However, these experiences did not always deter one from
using manual means of lifting or mobilizing patients. In this study,
physical barriers such as lack of space or time to use SPHM technology
and deficits in knowledge and skill were described as factors that in-
fluenced one's decision not to use SPHM equipment even when personal
risk was known or perceived. Other reports conclude that access to
equipment and confidence gleaned from knowledge in use of the
equipment promote its use (Olkowski & Stolfi, 2014).
As indicated earlier, collaboration with occupational and physical
therapy staff was an important factor in RN and NA decision-making
about whether to use SPHM technology to assist in patient mobilization.
This finding is commensurate with current trends in healthcare to
promote inter-professional collaboration to optimize patient outcomes.
7. Strengths and limitations
Focus groups provided a beneficial method of data collection for the
research question. Participants' engagement contributed to detailed,
rich descriptions of RN and NA experiences. Homogeneous grouping of
RNs and NAs with like peers may have contributed to engagement of
the participants. In addition, scheduled and supported time away from
participants' direct care assignments was beneficial to the overall focus
group experience. Qualitative thematic analysis included measures to
assure rigor and trustworthiness. Three researchers used an iterative
process of reading and independently coding the transcripts. Themes
and subthemes were derived from the researchers' collective analyses.
Findings from qualitative studies are not generalizable across health-
care facilities but may be transferable. A limitation of the study is that it
included subjects from one academic medical center. In addition, study
participants included RNs and NAs working primarily daytime hours
and did not explore the unique challenges facing staff during evening
and nighttime hours.
8. Implications for practice, education and research
Study findings have implications for practice, education, and re-
search. Implementation of ANA Safe Patient Handling and Mobility -
Interprofessional National Standards across the Care Continuum (2013)
and enforcement of OSHA guidelines require internal policy develop-
ment. Multiple approaches are required to adopt and sustain practice
changes that promote a culture of safety (Bhimani, 2014; Schoenfisch,
Myers, et al., 2011; Thomas & Thomas, 2014) including work flow
processes, education upon hire and ongoing competency assessment.
Unit champions or facilitators are needed to teach, role model beha-
viors, and monitor appropriate use (Elnitsky, Powell-Cope, Besterman-
M.L. Kanaskie, C. Snyder
Dahan, Rugs, & Ullrich, 2015). Additional measures of program effec-
tiveness and policy compliance include: support from nurse managers
and nurse educators, periodic walk-through assessments by institu-
tional leadership, and review of purchasing data to determine actual
use (Powell-Cope et al., 2014). Finally, inter-professional collaboration
with physical and occupational therapists to design practice standards,
educate peers, and monitor for sustainability is needed.
Knowledge gained may also inform nurse leaders across the care
continuum to develop plans for implementation of workplace safety
standards. Celona (2014) presents the business case for justification of
the investment which includes anticipated direct financial benefits such
as reduction in worker's compensation and lost and restricted days in
addition to reduction in pressure ulcers and patient falls (Celona, 2014).
Indirect financial benefits may include reduced turnover and improved
staff and patient satisfaction. As reported in these findings, purchasing
equipment along with initial training will not ensure proper use.
Studies are needed to evaluate interventions and sustainment of
change, as well as those which study effective quality improvement
processes. Male and female participants in this study reported gender
differences. Specifically, males were frequently asked to assist with
patient mobility procedures. Studies related to gender differences and
potential safety risks are worthy of exploration.
9. Conclusions
Findings of this study provide new information about the com-
plexity of decision-making by RNs and NAs in use of SPHM technology.
The data indicate that a nurse's confidence in assessment of the patient's
physical abilities is an important component in the nurse's decision to
promote patient mobility. Consultation with physical therapists and
occupational therapists is viewed as an important factor of RN and NA
decisions to promote patient mobility and to use SPHM technology.
Interprofessional collaboration, along with a multi-component SPHM
program, is essential for creating a culture of safety for safe patient
handling and mobility. These findings increase our understanding of the
factors influencing RN and NA decisions to use SPHM technology and
provide an important component for successful implementation of
SPHM programs and long term health of the nursing workforce.
Conflict of interests
None to declare.
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