Disability and Rehabilitation

ISSN: 0963-8288 (Print) 1464-5165 (Online) Journal homepage: http://www.tandfonline.com/loi/idre20

An exploration of knowledge and practice of patient handling among undergraduate occupational therapy students Margaret Mc Grath, Ciara Taaffe & Aideen Gallagher To cite this article: Margaret Mc Grath, Ciara Taaffe & Aideen Gallagher (2015) An exploration of knowledge and practice of patient handling among undergraduate occupational therapy students, Disability and Rehabilitation, 37:25, 2375-2381, DOI: 10.3109/09638288.2015.1019012 To link to this article: http://dx.doi.org/10.3109/09638288.2015.1019012

Published online: 04 Mar 2015.

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Date: 02 November 2015, At: 17:15

http://informahealthcare.com/dre ISSN 0963-8288 print/ISSN 1464-5165 online Disabil Rehabil, 2015; 37(25): 2375–2381 ! 2015 Informa UK Ltd. DOI: 10.3109/09638288.2015.1019012

EDUCATION AND TRAINING

An exploration of knowledge and practice of patient handling among undergraduate occupational therapy students Margaret Mc Grath1*, Ciara Taaffe1y, and Aideen Gallagher2 1

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Discipline of Occupational Therapy, School of Health Sciences, Faculty of Medicine, Nursing and Health Sciences, National University of Ireland, Galway, Ireland and 2Ryde Community Mental Health, Eastwood, New South Wales, Australia Abstract

Keywords

Purpose: To explore knowledge and practice relating to patient handling among final year occupational therapy students in the Republic of Ireland. Method: We conducted a survey of final year students in three out of four occupational therapy programs in the Republic of Ireland (n ¼ 81). The survey measured students’ knowledge of manual handling principles and techniques and explored their experiences and ability to apply this knowledge to clinical situations. Results: All students (n ¼ 81) had undertaken training in patient handling. Just under half of students (n ¼ 35, 43.2%) had received additional training outside of the university setting. Overall knowledge of safe patient handling principles techniques and risk assessment was low (Mean Score ¼ 15.71/28; SD ¼ 3.81). Participants who received additional training achieved a lower mean total score (M ¼ 13.89, SD ¼ 3.54) than those who only undertook university-based training (M ¼ 18.11; SD ¼ 2.66; t(79) ¼ 5.87; p50.05). The majority of participants reported intermittent use of taught principles while on clinical practice placements (n ¼ 50, 61.8%) Reasons for not using taught principles included; selection of alternative technique by supervisor (n ¼ 30, 56.6%); lack of available equipment (n ¼ 13, 24.5%) and lack of time (n ¼ 13, 24.5%). Conclusions: While occupational therapy students in Ireland receive training in safe patient handling they appear to have limited knowledge of best practice and experience difficulties in applying their learning to clinical situations. There is an urgent need to consider the effectiveness of current educational strategies in this area.

Handling, Ireland, occupational therapy students, under-graduates History Received 12 September 2014 Revised 8 February 2015 Accepted 10 February 2015 Published online 4 March 2015

ä Implications for Rehabilitation     

Safe patient handling is a key component in preventing musculoskeletal injury among rehabilitation professionals The extent to which pre-professional training prepares rehabilitation professionals to practice safe patient handling is unclear Occupational therapy students in this study had limited knowledge of safe patient handling and had difficulty applying their learning to clinical practice Alternative education models are required to support development of safe patient handling skills. Educators may wish to consider how safe patient handling can be embedded across curricula to avoid the challenges of once off instruction and massed practice.

Introduction Rehabilitation professionals’ face a high risk of developing workrelated musculoskeletal disorders (WRMS) [1–5]. Among physiotherapists incidence rates of WRMS of between 20.7 and 92.4% *Current address: Discipline of Occupational Therapy, School of Medicine, Trinity College Dublin, The University of Dublin (Singapore), Singapore. yCurrent address: Winstedt Integration Therapy, Singapore. Address for correspondence: Margaret Mc Grath, Discipline of Occupational Therapy, School of Medicine, Faculty of Health Sciences, Trinity College Dublin, The University of Dublin (Singapore), c/o Nanyang Polytechnic, 180 Ang Mo Kio Avenue 8, Block B, Level 1 Room B.107, Singapore 569830, Singapore. Tel: +65 911 36497. Fax: +65 6459 7285. E-mail: [email protected]

have been reported in the literature [2,6–11]. Less research regarding the incidence of WRMS has been conducted among occupational therapists [12] although there is some evidence to suggest similar rates of injury. Dyrkacz et al. [13] found a selfreported WRMS rate of 50% among Canadian occupational therapists, while in Queensland, Passier and McPhail [14] report that 63% of occupational therapists had experienced one or more WRMS in the previous 12 months. 80.4% of these therapists reported one or more musculoskeletal injury of the course of their career [14]. Darragh et al. [15] found among American occupational therapists that 13.5% had experienced multiple work-related injuries over a 3-year period while Shamill et al. [16] suggest that work-related injury rates (of which WRSM are most common) among occupational therapists and physiotherapists increased from 10.5% to 13.5% between 2004 and 2006.

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The high incidence of WRMS reported among these professional groups may reflect the nature of care and rehabilitation practices. Many patients who participate in rehabilitation present with reduced mobility and limited capacity to complete basic transfers independently [17]. The provision of care and rehabilitation involves complex handling tasks including twisting, turning, lowering, pushing–pulling, prolonged standing and heavy or frequent lifting or bending [12,18–21]. These physical practices expose rehabilitation professionals to WRMS with Campo et al. [2] concluding that therapists who completed between 6 and 10 patient transfers per day were 2.4 times more likely to acquire a WRMS than those who did not transfer patients. The impact of WRMS is significant, not only for the individual therapist [22,23] but also for healthcare employers [24]. In relation to impacts upon the individual Passier and McPail [14] found that 22.3% of injured therapists reported a reduction in their usual leisure or recreational abilities while 10.5% described an impact on their ability to perform activities of daily living. Similar personal impacts were described by Dyrkacz [13] who report that 15.9% of therapists experiencing work-related injuries experienced long-term limitations in their personal lives. Gropelli and Corle [22] found that work-related injuries resulted in feelings of fear, anger and frustration combined with sadness due to a reduced ability to practice one’s profession. They also reported that injured therapists experienced anxiety regarding their future employment prospects and had an overall diminished quality of life. Although the true cost of WRMS to employers is difficult to quantify [25,26] costs to the employer include direct costs such as healthcare, disability and worker compensation costs and indirect costs such as lost productivity, loss of current or future earnings, loss of potential output and contribution to social care programs to support injured workers [25–27]. Darragh et al. [15] found that 25% of occupational therapists with WRMS had changed jobs or were considering changing jobs due to their injury. Dyrkacz [13] reported a much lower rate of employment cessation (7.5%) among Canadian occupational therapists however the authors highlight that a significant number of injured therapists reported continuing to work despite injury. Furthermore, over one-third of those who reported injuries required modification to their work schedules, additional equipment to compensate for their injury or had changed clinical area suggesting that even if therapists continue to work post-injury employers may continue to incur injury-related costs. Similar findings are reported by Passier and McPail [14] who found that just under one-fifth of occupational therapists (19.7%) with WRMS took leave from work and that 30% of therapists required their work tasks to be modified or reduced as a result of injury. Given the high incidence and cost of WRMS for healthcare professionals and their employers it is not surprising that increased attention has been paid to promotion of safe patient handling [28]. In many jurisdictions, patient handling practices are subject to regulatory control and mandatory training for healthcare professionals is common. However, concerns have been raised over the efficacy of current training methods with Clemes et al. [29] concluding that there is little evidence to support the use of educational-based training for either nursing students or nurses. Less is known about the effectiveness of manual handling training for occupational therapists however given the increasing rates of WRMS reported within the profession [13,14,16] it seems timely to investigate the extent to which manual handling training prepares occupational therapists to practice safely. In Ireland, as in many other countries, education for safe patient handling in occupational therapy is shared between the

Disabil Rehabil, 2015; 37(25): 2375–2381

university and clinical environment. Pre-professional students are introduced to the theoretical basis of patient handling and are provided with practical training in the classroom. Further training experiences are obtained during clinical education where student occupational therapists learn from observing and doing patient handling under supervision of qualified occupational therapists. Recognizing the vulnerabilities of occupational therapists as therapy providers requiring patient handling skills [12], the current study sought to knowledge of safe patient handling skills among pre-professional occupational therapy students in the Republic of Ireland.

Methods Participants This study used a cross-sectional survey design and recruited students from the four pre-professional occupational therapy programs in the Republic of Ireland. Three of these programs offer a 4-year program leading to a Bachelor of Science in Occupational Therapy while the fourth offers an accelerated 2year program leading to a Master of Science (Professional Qualification) in Occupational Therapy [30,31]. Permission was granted from three of the four institutions to recruit final year students to the study. The fourth institution was unable to participate in the study due to timing of clinical placements. Procedures Following approval by the appropriate program directors, the second author sent a recruitment email to all final year occupational therapy students in each of the three participating programs (n ¼ 81). This email contained detailed information about the research aims and objectives. All potential participants were assured that participation in the study was voluntary and that results would be kept confidential. Interested students were invited to meet with the researcher to complete the survey at a time and date that was convenient to them. Written consent was obtained from all participants in the study prior to data collection. Measures An adapted version of Swain et al.’s [32] survey of student nurses’ manual handling practices was used to collect data for the study. The survey had three sections and included dichotomized questions, alternative statements and menus of responses [32]. The first section was used to collect information relating to participants’ demographic characteristics. The second section focused on participants’ knowledge of manual handling techniques using three subscales. In the first subscale, participants were asked to classify commonly used manual handling techniques as ‘‘safe’’ ‘‘unsafe’’ or ‘‘don’t know’’. One point was awarded for each correct response, while zero points were awarded for incorrect or unsure answers giving a total possible score of 16. In the second subscale, participants were asked to categorize eight statements relating to principles of manual handling into correct and incorrect statements. Each correct response was awarded a score of 1 while incorrect responses were awarded a score of 0 giving a total possible score of 8. The risk assessment component involved participants explaining the acronym TILE in relation to assessment of manual handling tasks. Participants were awarded 1 point for each letter that was correctly identified. The final section collected information regarding participants’ experiences of manual handling and used case vignettes to explore participants’ clinical reasoning relating to manual handling tasks. Participants were asked to read a brief clinical scenario and to select the most appropriate manual handling technique. In order to

Patient handling

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examine the impact of clinical culture on practice, participants were also asked to indicate how they would respond to a senior colleague who consistently insisted upon using manual handling techniques known to be unsafe. Although the survey used was originally designed to measure knowledge of manual handling among nursing students in the United Kingdom [32] it has also been successfully used among physiotherapy students in the Republic of Ireland [33] indicating good face validity. Permission was sought and obtained from the survey authors to adapt the survey so that it met the needs of the study and to ensure face validity for the local occupational therapy context. Changes included the replacement of nurse/student nurse with occupational therapist/student occupational therapist. In addition references to the risk assessment acronym TAPE were replaced with a locally used acronym TILE and the term auxiliary lift was replaced with the term underarm lift in order to reflect local custom. Finally, the adapted survey was reviewed by two local experts in manual handling and was then piloted with third year undergraduate occupational therapy students from the authors’ institution. Following the pilot no further changes were made to the survey. Data from the pilot study were not included in the final analysis. Statistical analyses Raw data were entered into SPSS Version 20 for Mac (SPSS Inc., Chicago, IL). Descriptive statistics were used to explore participants’ knowledge and experience of manual handling. Independent t-tests and Chi-square tests were used to explore differences between participants’ knowledge and experiences of manual handling. Significance was set at p50.05

Results Eighty-one survey responses were received giving a 100% response rate. Full details of participants’ demographic characteristics and experiences of manual handling training are provided in Table 1. The majority of participants were female and undertaking a Bachelor of Science in Occupational Therapy. Participants’ age ranged from 20 to 37 years with a mean age of 24.04 years (SD ¼ 4.04 years). All of the respondents had received training in manual handling as part of their occupational therapy program. Just over two thirds of respondents (n ¼ 55, 67.9%) received this training during the first year of their program with the remaining third (n ¼ 26, 32.1%) receiving training during the second year of their studies. Just under half of participants (n ¼ 35, 43.2%) reported that they had received additional manual handling training other than that provided by their university. The mean length of time since receiving this additional training was 1.9 years (SD ¼ 1.8 years). Where participants had received additional training, 60% (n ¼ 21) reported that this training was offered as part of a clinical placement, 34.3% (n ¼ 12) as part of previous or current employments in the healthcare sector (n ¼ 12, 34.3%) and two participants (5.7%) reported receiving training as part of employment outside of the healthcare sector. The majority of participants who had received additional training (n ¼ 25, 71.4%) did not identify any differences between the content of the training they received as part of their university curriculum and the content of the additional training. All of the respondents had undertaken supervised clinical practice with a focus on physical rehabilitation, with 63% (n ¼ 51) having completed two supervised clinical placements in a physical rehabilitation setting and 21% (n ¼ 12) completed three clinical placements in a physical rehabilitation setting.

Table 1. Participants’ experiences (N ¼ 81).

demographic

n

characteristics

%

Age (Years) Gender Female 75 92.6 Male 6 7.4 Program type Bachelor of Science 59 72.8 Master of Science 22 27.2 Received additional manual handling training Yes 35 43.2 No 46 56.8

and

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Mean

SD

24.04

4.04

Table 2. Classification of safe and unsafe manual handling techniques (N ¼ 81).

Manual handling technique Bed mobility (Refers to repositioning client Hoist/Sling Bed ladder Monkey pole Underarm lift Kneel back technique Sliding sheets with weight transference Through arm lift Shoulder lift

Correct

Incorrect

Unsure

n

(%)

n

(%)

n

(%)

in bed) 77 95.1 31 38.3 47 58 43 53.1 16 19.7 67 82.7 41 50.6 44 54.3

1 15 13 19 54 5 12 9

1.2 18.5 16 23.5 66 6.2 14.8 11.1

3 35 21 18 11 9 28 28

3.7 43.2 25.9 22.2 13.7 11.1 34.6 34.6

13 2 49 10 8 2 4 6 22

16 2.5 60.5 12.3 9.9 2.5 4.9 7.4 27.2

34 3 23 26 35 26 29

42 3.7 28.4 32.1 43.2 32.1 36

Transfers (e.g. moving client from bed to chair) Cross arm technique for sit to stand 34 Sliding board assistance 76 Front assisted stand and pivot transfer 9 Handling belt assistance 45 Turning disc assistance 38 Turning device with frame support 53 Standing and raising aid 47 Hoist/sling 75 Rocking lift 9

42 93.8 11.1 55.6 46.9 65.4 58 92.6 11.1

50 61.7

Techniques known to be risky are highlighted in bold.

Knowledge of manual handling principles and techniques Participants were asked to identify safe and unsafe techniques from a list of 16. The mean total knowledge of techniques was 9.22 (SD ¼ 3). None of the participants classified all of the techniques correctly. Table 2 provides full details of participants’ responses. Participants were also asked to identify correct principles of manual handling from a list of 8. Participants’ mean total score was 6.14 (SD ¼ 1.87). Just under 20% of participants (n ¼ 16) were able to correctly classify all of the statements. Participants demonstrated lack of awareness of the need to keep arms in line with the trunk during manual handling tasks (n ¼ 40, 49.4%) and of the use of weight transference (n ¼ 30, 37%). Full details of participants’ responses to these statements are provided in Table 3. The majority of participants (n ¼ 67, 82.7%) were unable to identify the risk assessment acronym with only one participant answering correctly. Participants mean total score of this question was 0.36 (SD ¼ 0.87). Participants’ scores on each of the three knowledge subscales were combined to give an overall total knowledge score (out of a maximum 28). The mean total knowledge score was 15.71 (SD ¼ 3.81). Participants’ scores ranged from 5 to 23 and none of the participants answered all questions correctly.

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Table 3. Knowledge of principles of safe manual handling (N ¼ 81). Correct

Ensure a firm hold of load Keep the load at a distance from your trunk Maintain neutral spinal alignment Minimize your base of support Avoid twisting or side flexing trunk Keep arms in line with trunk Ensure a flexed head position Avoid weight transference

Table 4. Use of manual handling techniques (N ¼ 80).

Incorrect

N

%

n

%

66 66 63 72 64 41 73 51

81.5 81.5 77.8 88.9 79.0 50.6 90.1 63

15 15 18 9 16 40 8 30

18.5 18.5 22.2 11.1 19.8 49.4 9.9 37.0

Correct principles are highlighted in bold.

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Relationship between overall knowledge and manual handling training An independent samples t-test was conducted to compare the total knowledge scores of participants who had received additional manual handling and those who had only completed manual handling training as part of their university curriculum. Participants who had received additional training in manual handling achieved lower mean total knowledge scores (M ¼ 13.89, SD ¼ 3.54) than those who had only received university-based training [M ¼ 18.11, SD ¼ 2.66; t(79) ¼ 5.87, p50.05, two-tailed]. The magnitude of the difference in the means (mean difference ¼ 4.22, 95% CI: 5.65 to 2.8) was large (eta squared ¼ 0.65). Application of manual handling principles and techniques Just under one-quarter of participants (n ¼ 18, 22.2%) reported that they always used the manual-handling principles recommended during training whilst undertaking clinical education, with the majority (n ¼ 50, 61.8%) reporting intermittent (sometimes/often) use of these principles. Eleven participants (13.5%) indicated that they had rarely used taught principles. Fifty-seven participants provided reasons behind their failure to follow taught principles; 56.6% (n ¼ 30) reported a selection of an alternative technique by the clinical supervisor; 26.4% (n ¼ 14) lack of manual handling equipment; 24.5% (n ¼ 13) identified a lack of time and 19.3% (n ¼ 11) a lack of risk assessment. Participants were provided with a list of commonly used manual handling techniques and asked to indicate if they had used these techniques while completing supervised clinical practice. Eighty participants answered this question and full details of their responses are provided in Table 4. The most commonly used technique was hoist/sling (n ¼ 65, 80.2%) followed by sliding board (n ¼ 56, 69.1%) and sliding sheets with weight transference (n ¼ 41, 50.6%). Participants frequently reported using controversial manual handling techniques including front assisted stand and pivot transfer (n ¼ 40, 49.4%); underarm lift (n ¼ 36, 44.4%); cross arm technique for sit to stand (n ¼ 15, 18.5%); rocking lift (n ¼ 18, 22.2%) and through arm lift (n ¼ 14, 17.3%). The majority of participants (n ¼ 57, 70%) reported that they had experienced a situation where a supervisor or senior therapist suggested using a manual handling technique that they knew was unsafe. Just under one-third of participants (n ¼ 25, 30.8%) reported saying nothing in this situation. Participants’ explanations for their behavior despite knowing that the technique was unsafe were: not knowing an alternative technique (n ¼ 20, 80%); the client was in distress (n ¼ 5, 20%); feared a negative impact on own grade (n ¼ 5, 20%); and insufficient time (n ¼ 2, 8%). Chi-square tests for independence indicated no significant association between participation in additional manual handling

Used during supervised practice Manual handling technique

n

Bed Mobility (Refers to repositioning client in bed) Hoist/Sling 65 Bed Ladder 12 Monkey Pole 0 Underarm Lift 36 Kneel back technique 17 Sliding sheets with weight transference 41 Through arm lift 14 Shoulder lift 12 Transfers (e.g. moving client from bed to chair) Cross arm technique for sit to stand 15 Sliding board assistance 56 Front assisted stand and pivot transfer 40 Handling belt assistance 26 Turning disc assistance 21 Turning device with frame support 24 Standing and raising aid 23 Hoist/sling 65 Rocking lift 18

(%) 80.2 14.8 0 44.4 21.2 50.6 17.3 14.8 18.5 69.1 49.4 32.1 25.9 29.6 28.4 80.2 22.2

Techniques known to be unsafe are highlighted in bold.

training and use of recommended techniques, use of incorrect techniques or willingness to respond to unsafe techniques. Application of knowledge to clinical scenarios Participants’ clinical reasoning relating to manual handling tasks was explored further by examining their responses to two different clinical scenarios. In the first scenario, participants were presented with details of a hypothetical patient and asked to select the most appropriate manual handling technique. The majority of participants (n ¼ 48, 59.3%) selected an appropriate manual handling technique, while a further four participants (4.9%) reporting that they were unsure of the correct techniques and the remaining 26 participants (32.1%) selected an inappropriate technique. No significant difference in total knowledge of manual handling principles and selection of techniques was found between those who identified the correct techniques (M ¼ 15.75, SD ¼ 3.8) and those who did not [M ¼ 15.35, SD ¼ 3.8; t(72) ¼ 0.44, p ¼ 0.66 two-tailed]. In the second scenario, participants were asked to indicate how they would respond to a senior colleague who consistently insisted upon using a manual handling technique known to be unsafe. Half of the participants (n ¼ 41, 50.6%) reported that they would suggest an alternative technique but ultimately would follow the directions of the senior therapist. A further four participants (4.9%) indicated that they would follow the directions of the senior therapist without discussion while the remaining participants (n ¼ 33, 40.7%) indicated that they would refuse to follow the instructions of the senior therapist. Following recoding of the data into ‘‘do as directed’’ and ‘‘refuse’’ independent samples t-tests indicated no difference in total knowledge scores or age between those who refused to follow unsafe practice and those who did as the senior therapist directed.

Discussion This research set out to explore knowledge and experiences of manual handling among the occupational therapy students in Ireland. The results support research that challenges the effectiveness of manual handling training as a sole intervention and suggest that caution should be applied to the assumption that

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training leads to acquisition of knowledge and understanding of the principles of safe patient handling [29,34–38]. All of the participants in this study had undertaken manual handling training as part of their occupational therapy studies. This finding reflects international practice in occupational therapy education [39,40] and responds to the need for graduate occupational therapists to be prepared to assume responsibility not only for patient handling tasks [5,12] but also for training carers and other healthcare professionals in safe handling [5,39,41]. While it is encouraging that manual handling has been included in university curricula the level of knowledge of manual handling, manual handling in this study was lower than those reported among student nurses [32] and student physiotherapists [33] using the same measure. This finding is disappointing and points to the need to consider both the content and timing of manual handling training within occupational therapy curricula in Ireland. Detailed examination of the curricula relating to manual handling in each of the universities was outside of the scope of the study however the majority of participants in this study undertook training early in their programs and for most part teaching took place in blocked sessions prior to clinical placements. Moulton et al. [42] found that acquisition and retention of clinical skills is enhanced using distributed practice regimens rather than relying upon once off massed instruction and there is evidence to suggest that integration of clinical skills teaching across curricula may be more effective than once off teaching [43]. It may be that occupational therapy students’ knowledge of manual handling would be enhanced by provision of additional training distributed across the curriculum and this finding warrants further exploration. Furthermore, despite having received university training just under half of participants had also undertaken additional ‘‘on the job’’ training suggesting perhaps that the university-based curricula does not provide sufficient knowledge or experience to prepare students for the realities of clinical practice. Again this is not a new finding and in Ireland Ambrose and Keating [33] report that 30% of physiotherapy students engaged in additional manual handling training outside of the university setting. Similarly, within occupational therapy, Rice et al. [5] found that over 46% of therapists described ‘‘on the job’’ training as the primary source of education regarding safe patient handling. Although ‘‘on the job’’ training offers the opportunity to fill gaps in students’ knowledge and to ensure that knowledge is connected to clinical practice, the extent to which ‘‘on the job’’ training reflects best practice in manual handling rather than local ‘‘custom and practice’’ is unclear. Research suggests that healthcare students are frequently exposed to poor manual handling practice [32,44– 46] and as Rice et al. [5] point out informal ‘‘on the job’’ training is rarely subject to formal guidelines or educational criteria associated with formal education. In this study, additional training had a negative impact upon knowledge of safe manual handling principles. There are a number of possible interpretations of this finding. First, it may be that those students who received additional training had demonstrated lower levels of competence in safe patient handling than those who did not. Second, although the majority of participants did not report differences between the content of university curricula and additional training it may be that there is a lack of consistency regarding the content of training that may have resulted in confusion and poorer performance. Although the data collected during the current study do not enable definite conclusions to be drawn both interpretations point to the need for further exploration of the efficacy of university-based training in preparing students for the reality of clinical practice. Participants’ lack of knowledge of principles and techniques of manual handling may offer one explanation for the failure to

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implement principles of safe manual handling and the use of known high-risk techniques. As Kay and Glass [34] note without understanding of relevant principles healthcare professionals cannot develop associated safe handling skills. However, we suggest that the results also point toward the need to consider organizational and professional culture when attempting to promote safer patient handling. Participants reported that they frequently used techniques such as front assisted stand and pivot, underarm lifts, rocking lifts and through arm lifts, all of which been associated with high risk of injury to healthcare professionals and patients [47–49] and consequently are not recommended for use in practice [47,50–52]. It is unlikely that students would be taught high risk techniques such as those described by Chnell [52], Retsas [48], Kaye [45] and others [47,50,51] since current training emphasises minimal lifting approaches. Therefore, it is important to consider why students are experiencing and participating in continued use of out dated techniques and why they are prepared to risk injury to themselves and others. Existing research that has explored similar patterns of non-compliance with recommended techniques consistently point towards the influence of other staff on students’ behavior [32,53–55]. The findings of this study support this conclusion with students frequently referring to the senior therapist as the source of decision-making. While it could be argued that students may have a tendency to report themselves as following the advice of others rather than personally selecting incorrect principles and techniques the impact of the power imbalance which exists in the student–clinical supervisor relationship should not be underestimated [56,57]. Thus, education must focus not only on developing knowledge but also on preparing students for the realities of practice and supporting them to be advocates for change [45,54]. Participants also identified lack of time as a significant reason for not following recommended manual handling principles and techniques. Again, lack of time is frequently reported as a reason for poor manual handling practices within healthcare [32,53–55] and points need to consider the extent to which manual handling training prepares students to apply their learning in complex and hectic environments. Resnick [58] notes that manual handling training is frequently delivered in clinical skills laboratories or empty patient bays and as such cannot replicate the demands of working hospital and rehabilitation environments. Instead it is suggested that manual handling training should be contextualized and designed to meet the needs of specific clinical environments and that training should offer realistic scenarios where students can apply their learning in the context in which they practice [58]. The finding that students would consider unsafe practices if a patient was in distress raises interesting questions regarding how therapist personal safety is understood and valued within rehabilitation settings. Existing research relating to incidences of WRMS among the occupational therapists points to patterns of underreporting [5,13] and impaired presenteeism [59] suggesting that occupational therapists are reluctant to report injury to them or to modify their work schedules. However, if therapists are to provide ongoing high quality care for their clients and to avoid professional burnout due to injury, they must ensure that their own safety is equally protected. Limitations of the study Several limitations in the current study deserve consideration when interpreting the results. First, the use of survey research as the method of inquiry means that there is a potential for response bias and non-response bias, which may influence the results of the study. Participants in the survey may not have recalled

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information correctly or they may have interpreted the questions in the survey in a differently than the meaning intended. Although the survey was distributed among three out of four occupational therapy programs in the Republic of Ireland, it is possible that students from the program who did not participate in the study may have had different knowledge and experiences of manual handling. Finally, although the survey has been used to explore knowledge and experiences of manual handing among a number of groups of healthcare students [32,33], there is a need to examine the psychometric properties in greater detail.

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Conclusions The nature of rehabilitation places occupational therapists at risk of developing WRMD with significant consequences for individuals, their employers and the profession. Younger less experienced therapists are more likely to sustain WRMSD than their older colleagues [12,21] and so it is vital that early educational experiences support occupational therapy students to develop safe and competent practice relating to patient handling tasks. Our research suggests that while occupational therapy students in Ireland receive instruction in safe patient handling they have limited knowledge of best practice in this area and have difficulty applying their learning to the clinical context. We suggest that there is an urgent need to consider the effectiveness of current educational strategies in relation to development of skills in safe patient handling. Given the significant burden caused by poor manual handling practices in healthcare environments attention must be paid to the influence of professional culture on the uptake and use of recommended guidelines. Finally, further research is necessary to identify alternative models of education that can address the deficits in knowledge and practice identified in this study.

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10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21.

22. 23.

Declaration of interest The authors declare no conflict of interest.

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An exploration of knowledge and practice of patient handling among undergraduate occupational therapy students.

To explore knowledge and practice relating to patient handling among final year occupational therapy students in the Republic of Ireland...
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