Educational Innovations
Interprofessional Teaching Project With Nursing and Physical Therapy Students to Promote Caregiver and Patient Safety Shelley von der Lancken, MSN, RN; and Kim Levenhagen, PT, DPT, WCC
ABSTRACT Nurse educators must adjust curricula to meet the dynamic and critical changes in the health care environment, and to recognize the risk of injury our educational approach has on safety, team effectiveness, and culture change. Interprofessional collaboration and simulation are key components in the preparation of our students. Utilizing the interprofessional alliance model, an experience to promote collaborative relationships among nursing and physical therapy (PT) students to improve patient and caregiver safety was developed. Through this model, PT students taught safe patient-handling skills in a simulated setting to undergraduate nursing students. The majority of nursing students (N = 351) from 2009-2014 strongly agreed or agreed that they were confident in the skills taught by the PT students and provided an overall course rating of outstanding or above average. This educational model, which includes simulation and safe patient handling, was a valuable addition to the curriculum, reinforcing the significance of developing collaborative relationships. [J Nurs Educ. 2014;53(12):704-709.]
N
ursing personnel is listed as the fifth ranked occupation for work-related musculoskeletal disorders (MSDs) (U.S. Department of Labor, 2013). Work-related MSDs, such as back and shoulder injuries, persist as the leading and most costly U.S. occupational health problem for nursing (American Nurses Association [ANA], 2009). Chronic back pain and environmental risk lead 12% to 18% of nursing personnel to leave the profession annually or to request transfer away from bedside care (Nelson & Baptiste, 2004). However, this problem is not exclusive to the nursing profession. Kneafsey, Ramsay, Edwards, and Callaghan (2012) reported that 40% of the 371 undergraduate nursing and physical therapy (PT) students surveyed admitted to performing unsafe moving and handling activities. Another 50% stated they would rather fit into the team than challenge unsafe practice (Kneafsey et al., 2012). In addition, 29% stated they had begun to experience pain since becoming a student (Kneafsey et al., 2012). The Patient Handling and Movement Assessments white paper by Cohen et al., (2010) noted a slowly growing appreciation and policy development related to safe patient handling. It is important for health care educators to recognize the risk of injury as we focus our educational approach on safety, team effectiveness, and culture change. Curricular revisions must focus student and faculty attention to personal and patient safety, considering the challenges of a more critical care environment.
Background and Significance
Received: May 29, 2014 Accepted: August 26, 2014 Posted Online: November 26, 2014 Ms. von der Lancken is Instructor, School of Nursing, and Dr. Levenhagen is Assistant Professor, Physical Therapy Program, Saint Louis University, Saint Louis, Missouri. The authors have disclosed no potential conflicts of interest, financial or otherwise. Address correspondence to Shelley von der Lancken, MSN, RN, Instructor, School of Nursing, Saint Louis University, 3525 Caroline Street, Room 329, Saint Louis, MO 63104; e-mail: [email protected]. doi:10.3928/01484834-20141118-14
704
The Handle With Care campaign was initiated by the ANA to advocate for policies to eliminate patient handling and reduce injury rates (de Castro, 2004). The campaign highlights the impact of musculoskeletal injuries on nursing professionals and suggests educational efforts to support a no-lift environment. A no-lift policy states that all manual handling tasks should be avoided whenever possible. The Patient Handling and Movement Assessments (Cohen et al., 2010) report recommends the use of equipment, although health care teams perform high-risk tasks that do not currently have safe solutions (Cohen et al., 2010). Wardell (2007) reported that despite training and sufficient equipment, 71% of the study participants did not use equipment, including slide sheets. Lee, Faucett, Gillen, and Krause (2013) surveyed critical care nurses about pain, lift availability and use, physical and psychosocial job factors, and sociodemographics. In their results, less than half (46%) of respondents reported that their employer provided lifts (Lee et al., 2013). When lifts were Copyright © SLACK Incorporated
EDUCATIONAL INNOVATIONS
available and used, a significant reduction in back and shoulder injuries resulted (Lee et al., 2013). Some health care environments provide education and safe patient handling equipment for health care providers; however, the culture and leadership in most settings has yet to make this agenda a priority. Nurses and PTs are challenged with early mobilization of an increasingly dependent, obese, and sicker patient population. Caregivers are asked to do more with less, as reimbursement for services and capital equipment have been more closely scrutinized. Thus, the patient population will require earlier mobilization, as reimbursement is increasingly tied to quality and efficiency. Research supports the significance of early mobilization to prevent postoperative complications and minimize health care–associated risks, which may create significant savings for the health care system (Cohen et al., 2010; Lewis, Dirksen, Heitkemper, Bucher, & Camera, 2011; Sarni, 2010). The challenges in the current health care environment necessitate an interdisciplinary team approach to care. Educators must revise curricula to reinforce this interprofessional relationship to include understanding the risk of injury and collaborating and advocating for an environment of safe care. In May 2013, the ANA published the Safe Patient Handling and Mobility: Interprofessional National Standards for safe patient handling. These standards provide guidelines for care settings to develop and sustain a culture of safety, including roles for all members of the health care team. Role identity, collaboration, and team effectiveness must be included in higher education to prepare students for today’s challenges. Little has been published regarding the interprofessional preparation of nursing students related to safe patient handling and movement. The purpose of this article is to describe a model promoting collaborative relationships among nursing and PT students to improve patient and caregiver safety. Through this model, the PT students teach safe patient handling skills in a simulation setting to undergraduate nursing students. In addition to learning skills, the students gain a better understanding of each other’s professional roles.
Interprofessional Collaboration Model Among Nursing and PT Students In 2006, a midwestern university initiated an interprofessional education program (IPE) as part of the core curriculum for students in nine health professional degree programs, including PT, occupational therapy, nutrition and dietetics, athletic training, and clinical laboratory science. The university’s IPE curriculum includes four interprofessional courses that allow students to accumulate 9 credit hours by the time they graduate from their professional programs. Students enroll in IPE courses at the beginning of their educational programs. The IPE curriculum includes interactive learning experiences that identify the roles of the health care team and the importance of effective teamwork. In 2009, the school of nursing and the physical therapy program expanded on the curricular theme by developing a simulated learning experience. This student-led experience includes caregiver and patient safety in an environment that fosters teamwork and respect. The faculty utilized the interprofessional Journal of Nursing Education • Vol. 53, No. 12, 2014
Figure. Interdisciplinary alliance model. From “Interprofessional Collaborative Alliances: Health Care Educators Sharing and Learning From Each Other,” by L.M. Hayward, R. DeMarco, and M.M. Lynch, 2000, Journal of Allied Health, 29, pp. 220-226. Copyright 2000 by the Association of Schools of Allied Health Professions. Reprinted with permission.
alliance model (IPAM) developed by Hayward, DeMarco, and Lynch (2000) to improve collaboration among health care professionals (Hayward et al., 2000). The Figure shows the seven phases of the IPAM. In phase I, the faculty recognized the value of collaboration on patient outcomes and caregiver safety. In phase II, a deficit in the nursing curriculum was identified that was related to safe patient handling. In addition, the PT students needed an environment in which to improve their communication skills with other health care professionals. The PT students had a strong foundation in the area of safe patient handling, making this an ideal collaborative effort. In phase III, monthly meetings identified the benefits of this collaborative experience in the curriculum. During these meetings, course objectives, evaluation criteria, and the logistics of managing the experience between two professional programs were outlined. It was determined that this interprofessional, student-led experience would develop effective team building and communication. Challenges were presented during the planning phase. The students had scheduling difficulties with other curricular requirements. In phase IV, each program made the simulation experience a priority, after recognizing the value of this professional alliance. The students had full support of faculty and quickly recognized that the collaborative effort was an incredible opportunity to affect the care and satisfaction of both students and future patients. After presenting the objectives and course plan with university administrators and the director of the IPE, the decision to commit to a formal collaborative relationship was established in phase V. Phase VI of the IPAM was the project implementation phase. The nursing students were in their third year of a 4-year baccalaureate program and were ready to begin clinical rotations for nursing care of adult and older adult patients. The PT students were in their second year of the professional phase of the Doctor of Physical Therapy program. The PT students developed objectives, a lesson plan, and handouts and provided construc705
EDUCATIONAL INNOVATIONS
TABLE 1 Course Objectives for Physical Therapy and Nursing Students Course
Overall Course Objective
Nursing
• Demonstrate clinical judgment and psychomotor skills necessary for safe and competent practice. • Communicate clearly and effectively using written, verbal, nonverbal, and technologic methods. • Utilize interprofessional communication and collaboration to provide holistic, high-quality, and safe patient care.
Physical therapy
• Value the role of feedback and self-evaluation in the process of learning. • Reflect on his or her practice, learning, and teaching of select communication skills.
Simulation learning experience led by physical therapy students
• Demonstrate bed mobility transfers with proper body mechanics, without cues. • Perform pivot transfer techniques with proper body mechanics, without cues. • Demonstrate appropriate guarding during patient ambulation with a walker, with cues less than 25% of the time. • Provide proper instruction to a patient performing a sit-to-stand transfer using a gait belt, without cues. • Recall three reasons to use proper body mechanics during safe patient-handling transfers, without cues. • Justify a selected transfer technique in a case scenario, with less than 25% cues from the physical therapy students.
tive feedback to the nursing students. Table 1 provides the overall course and PT student objectives. The PT students teaching the program started with a brief overview of the objectives and the incidence and prevalence of musculoskeletal disorders for health care providers. The PT students then provided instruction in a simulated patient care setting to teach nursing students the correct way to facilitate patient transfers, bed mobility, and gait using assistive devices. The simulated setting was housed in the physical therapy program’s laboratory, which included wheelchairs, gait belts, assistive devices, and lifts. The safe patient-handling simulation sessions provided the PT students with an opportunity to apply learning theories and to develop teaching skills. This pedagogical approach was supported by the National Institute for Occupational Safety and Health, the Veterans Health Administration, and the ANA (Waters, Nelson, Hughes, & Menzel, 2009), which advocate for safe manual handling techniques in conjunction with equipment and technology. The PT students included concepts supporting a minimal-lift and a no-lift environment as they introduced gait belts, slide boards, friction-reducing sheets, and patient assistive devices. The Egress test was included to establish nursing confidence in moving patients prior to a PT evaluation. The Egress test includes three repitions of sit-to-stand, three steps of marching in place, and advance step and return of each foot (Dionne, 2004). The nursing students mirrored the demonstration of the patient movement and transfers to validate understanding. The PT students provided feedback and a competency checklist of skills to the nursing students of their performance. Table 2 provides a list of skills performed by the nursing students. Collaboration and role identity, along with caregiver and patient safety, were priorities during the student interaction. The learning environment was comfortable, positive, and collaborative as PT students led the experience in small groups, encouraging discussion of clinical experiences. Phase VII of the IPAM invites group members to plan future research or educational efforts after a retrospective review of 706
evaluative data. The group met and decided to continue with the program and to offer additional complex care simulations that recognize the increased acuity of the patient population. In fall 2013, additional case scenarios were created for the same cohort of nursing students in their fourth year of study to build on previous experiences. The cases included patients with chronic and acute pain, partial- and nonweight-bearing status, hemiparesis, obesity, wound care, injury after a fall, postoperative activity desaturations, and hemodynamic instability. The nursing students worked in groups to discuss a plan of care for each scenario. The assignment challenged the nursing students to identify the role of each discipline in the care of the patient. The nursing and PT students then simulated safe patient handling and movement for each scenario. Strengthening the relationship and role identification is important in improving caregiver safety, workplace satisfaction, and clinical outcomes for patients. The students discussed the importance of collaboration and role identity related to patient activity and outcomes. Understanding roles and communication are important competencies for patient-centered collaborative practice (Suter et al., 2009).
Method The authors developed a study to gather feedback from the junior-year nursing students about their experience of the student-led simulation and psychomotor mastery. Following institutional review board approval, the questionnaire was distributed to the nursing students during 2009-2014 academic years by the PT students at the completion of the safe patientmovement experience. Completion of the questionnaire was voluntary, and responses were anonymous. The questions were consistent, except for 2011 in which one question was inadvertently dropped and another question was revised. Responses were based on a 4-point Likert scale (1 = strongly agree, 2 = agree, 3 = disagree, 4 = strongly disagree). The questionnaire included questions about the students’ satisfaction with the course and what they learned. Copyright © SLACK Incorporated
EDUCATIONAL INNOVATIONS
In addition, the nursing students rated their overall experience with the course. Responses for the overall experience were based on a 5-point Likert scale (1 = outstanding, 2 = above average, 3 = average, 4 = below average, 5 = very poor) and were included for all years. Descriptive statistics were calculated from the 4- and 5-point Likert scale responses. Nursing students were provided with an opportunity to write in additional comments, providing qualitative data for analysis. Written comments to open-ended questions regarding the overall perception of the course were reviewed for themes. The PT students reflected on course feedback and identified areas needing improvement in future instructional courses requiring interprofessional communication. The experience improved the PT students’ awareness regarding the significance of a work-related injury. Furthermore, the PT students did not realize that each psychomotor skill required specific instruction due to the lack of knowledge regarding safe patient handling skills in the nursing curriculum. In addition, the PT students recognized the importance of collaborative communication, as the nursing students provided new scenarios that the PT students had not experienced on previous clinical experiences. This reinforced the fact that professionals cannot work in silos but need to learn from one another to promote caregiver safety. Students from the PT program completed a reflection paper at the end to the interprofessional teaching experience demonstrating these lessons learned.
Results The number of respondents completing the questionnaires in the Nursing Care of Adults and Older Adults course were 351 (54 in 2009, 60 in 2010, 54 in 2011, 61 in 2012, 63 in 2013, and 59 in 2014). Table 3 provides feedback from the nursing students regarding the level of satisfaction of the interprofessional experience led by the PT students enrolled in the Components of Effective Communication and Teaching course. Specifically, Table 3 demonstrates that the majority of respondents strongly agreed or agreed that the course was organized, the objectives were clear, and the experience enhanced their learning. In addition, the respondents identified how confident they were in performing or understanding the skills as taught in the course. The majority (98.3%, 100%, respectively) of respondents strongly agreed or agreed that they were confident in performing or understanding the skills taught. The majority (96.2%, 100%, respectively) of respondents rated the course as outstanding or above average. Qualitative Data
Several themes emerged, which included recognizing the importance of interprofessional collaboration and the significance of the curricular addition. The students appreciated the opportunity of the simulated interprofessional experience. Some comments from the nursing students included: “It was good to work with peers [PT students], and they were very knowledgeable and straightforward, but still fun,” “Good teamwork between the groups,” “The students/teachers seemed very passionate,” and “There should be more collaboration between PT and nursing students.” Journal of Nursing Education • Vol. 53, No. 12, 2014
TABLE 2 Skills Competency Checklist Skill
Completed
Transfer up/down and side-to-side in bed: Put the bed at the correct height (waist level when providing care, hip level when moving a patient). Transfer to bed to supine to short sitting: Keep the patient as close to your body as possible to minimize reaching. Rolling: Maintain a wide, stable base with your feet. One- and two-man pivot transfer: Try to keep the load directly in front of you to avoid rotating the spine. Sit to stand Gait with walker
The nursing students recognized the importance of the experience for patient and caregiver safety and suggested that the material be provided earlier in the nursing curriculum prior to engaging in patient care. Some comments reflecting this were: “This course would be more beneficial to sophomores, before they go into their clinical setting so that they can go in feeling more confident about their patient transport skills,” and “I wish I had received this instruction earlier, I have experienced a back injury and have pain.” Reflection From PT students
At the completion of the experience, the PT students were asked to reflect on their teaching skills and their interprofessional communication with the nursing students. The importance of the collaborative relationship and role identity was acknowledged by one student’s comments: “The strength of this opportunity was integrating two health professions together, learning from each other. Even though we were the ones teaching, we learned more about the nursing students and their experiences in the clinic.”
Discussion Providing safe patient-handling education to nursing students allowed a collaborative approach to improve the delivery of high-quality, safe, and efficient care in an increasingly complex health care environment. The educational experience must shift from one in which health profession students are educated in silos to one that fosters collaboration, communication, and a team approach to providing care (Interprofessional Education Collaborative, 2011). In the current study, feedback from the students and faculty was overwhelmingly positive. In reflecting on the student evaluations, the results were similar to research by Christie, Smith, and Bednarzyk (2007). Christie et al. reported that nutrition, nursing, and PT students enjoyed learning from other disciplines and gained a better understand707
EDUCATIONAL INNOVATIONS
riers and their ability to influence practice and safety.
TABLE 3 Nursing Students’ Evaluation of the Course
Question
Question Answered (n)
The organization of this course was evident.
347
Objectives of this course were made clear at the start of the course.
347
There was agreement between the announced course objectives and what was actually taught.
347
Questioning and demonstration in class enhanced my learning.
347
The laboratory experiences were well organized.
293a
Overall, I believe I can adequately perform the skills taught in this course.
293a
Overall, I have a better understanding of back safety and transfers. a b
Question was not included in 2011 evaluation questionnaire. Question was included only in 2011 evaluation questionnaire.
ing of their respective roles when given a written case scenario. The current research demonstrates that PT students have the expertise to be mentors for nursing students in a positive and comfortable learning environment. The small groups in the current study fostered collaboration and open communication. The IPAM provided a useful model for designing curricular changes within the school of nursing and the physical therapy program. The current model has been a successful student experience and continues to improve.
Study Limitations One limitation of this study was the scheduling and availability of the students. The consistency of PT students varied due to full-time clinical placement. Scheduling issues related to laboratory space and classroom time was challenging. Another limitation was a minor change in the questionnaire in 2011. However, the students had similar responses throughout the 5 years of the program, suggesting a positive experience.
Implications for Practice and Future Research Additional areas of research include the use of questionnaires concerning the availability of equipment, interprofessional collaboration, and the support in health care environments for safe patient handling and movement policies. Furthermore, the authors plan to use previously obtained student data to determine whether the experiences have changed the students’ attitudes and perceptions about working in collaborative teams. Surveys of the graduates, who are now in practice settings, will also be a key component of this initiative to identify environmental bar708
The current study education model that included simulation and safe patient 344 (99.1) 3 (0.9) handling was a valuable addition to the curriculum. Higher education curricula 346 (99.7) 1(0.3) must include collaboration in clinical or simulated care set345 (99.4) 2 (0.6) tings to address the complex care needs of patients and to improve team effective345 (99.4) 2 (0.6) ness (Suter et al., 2009). The IPAM model has reinforced 289 (98.6) 4 (1.4) the significance of this collaborative relationship, along 292 (99.7) 1 (0.3) with enhancing role identity for student participants. This 54 (100) 0 (0) model helps the students to understand their own roles and those of the health care team so that each member can work together in a respectful and inclusive environment (Ateah et al., 2011). Curricular modifications must emphasize the importance of a culture change in health care. Training of health care professionals can no longer occur in silos as we prepare our students to not approach care as individual experts but as expert teams.
Strongly Agree/ Agree (n, %)
54b
Conclusion Disagree/ Strongly Disagree (n, %)
References American Nurses Association. (2009). ANA supports safe patient handling measures in congress to improve safety of nurses and patients. Retrieved from http://safeliftingsolutions.com/docu/safe.pdf American Nurses Association. (2013). Safe patient handling and mobility: Interprofessional national standards. Silver Spring, MD: Author. Ateah, C.A., Snow, W., Wener, P., MacDonald, L., Metge, C., Davis, P., . . . Anderson J. (2011). Stereotyping as a barrier to collaboration: Does interprofessional education make a difference? Nurse Education Today, 31, 208-213. doi:10.1016/j.nedt.2010.06.004 Christie, C., Smith, A.R., Jr., & Bednarzyk, M. (2007). Transdisciplinary assignments in graduate health education as a model for future collaboration. Journal of Allied Health, 36, 67-71. Cohen, M.H., Nelson, G.G., Green, D.A., Leib, R., Matz, M.W., & Thomas, P.A. (2010). Patient handling and moving assessments: A white paper. Retrieved from http://www.fgiguidelines.org/pdfs/FGI_PHAMA_ whitepaper_042810.pdf de Castro, A.B. (2004). Handle with care®: The American Nurses Association’s campaign to address work-related musculoskeletal disorders. The Online Journal of Issues in Nursing, 9(3), Manuscript 2. Dionne, M. (2004). Introducing the egress test, A simple screening tool to predict safety of bariatric patients transfers. Advance Physical Therapists and PT Assistants, 15(13), 39-40. Hayward, L.M., DeMarco, R., & Lynch, M.M. (2000). Interprofessional collaborative alliances: Health care educators sharing and learning from each other. Journal of Allied Health, 29, 220-226. Interprofessional Education Collaborative. (2011). Team-based competencies: Building a shared foundation for education and clinical practice
Copyright © SLACK Incorporated
EDUCATIONAL INNOVATIONS
[Conference proceedings]. Washington, DC: Author. Retrieved from http://www.aacn.nche.edu/leading-initiatives/IPECProceedings.pdf Kneafsey, R., Ramsay, J., Edwards, H., & Callaghan, H. (2012). An exploration of undergraduate nursing and physiotherapy students’ views regarding education for patient handling. Journal of Clinical Nursing, 21, 3493-3503. doi:10.1111/j.1365-2702.2012.04172.x Lee, S.J., Faucett, J., Gillen, M., & Krause, N. (2013). Musculoskeletal pain among critical-care nurses by availability and use of patient lifting equipment: An analysis of cross-sectional survey data. International Journal of Nursing Studies, 50, 1648-1657. doi:10.1016/j. ijnurstu.2013.03.010 Lewis, S.L., Dirksen, S.R., Heitkemper, M.M., Bucher, L., & Camera, I. (2010). Medical-surgical nursing: Assessment and management of clinical problems (8th ed.). St. Louis, MO: Elsevier Mosby. Nelson, A., & Baptiste, A.S. (2004). Evidence-based practices for safe patient handling and movement. The Online Journal of Issues in Nursing, 9(3), Manuscript 3.
Journal of Nursing Education • Vol. 53, No. 12, 2014
Sarni, N. (2010). A short walk a day shortens the hospital stay: Physical activity and the demand for hospital services for older adults. Canadian Journal of Public Health, 101, 385-389. Suter, E., Arndt, J., Arthur, N., Parboosingh, J., Taylor, E., & Deutschlander, S. (2009). Role understanding and effective communication as core competencies for collaborative practice. Journal of Interprofessional Care, 23, 41-51. doi:10.1080/13561820802338579 U.S. Department of Labor, Bureau of Labor Statistics. (2013). Nonfatal occupational injuries and illnesses requiring days away from work, 2012 [Press release]. Retrieved from http://www.bls.gov/news.release/osh2. nr0.htm Wardell, H. (2007). Reduction of injuries associated with patient handling. American Association of Occupational Health Nurses Journal, 55, 407412. Waters, T., Nelson, A., Hughes, N., & Menzel, N. (2009). Safe patient handling training for schools of nursing: Curricular materials. North Charleston, NC: CreateSpace.
709
Interprofessional Teaching Project With Nursing and Physical Therapy Students to Promote Caregiver and Patient Safety Shelley von der Lancken, MSN, RN; and Kim Levenhagen, PT, DPT, WCC
ABSTRACT Nurse educators must adjust curricula to meet the dynamic and critical changes in the health care environment, and to recognize the risk of injury our educational approach has on safety, team effectiveness, and culture change. Interprofessional collaboration and simulation are key components in the preparation of our students. Utilizing the interprofessional alliance model, an experience to promote collaborative relationships among nursing and physical therapy (PT) students to improve patient and caregiver safety was developed. Through this model, PT students taught safe patient-handling skills in a simulated setting to undergraduate nursing students. The majority of nursing students (N = 351) from 2009-2014 strongly agreed or agreed that they were confident in the skills taught by the PT students and provided an overall course rating of outstanding or above average. This educational model, which includes simulation and safe patient handling, was a valuable addition to the curriculum, reinforcing the significance of developing collaborative relationships. [J Nurs Educ. 2014;53(12):704-709.]
N
ursing personnel is listed as the fifth ranked occupation for work-related musculoskeletal disorders (MSDs) (U.S. Department of Labor, 2013). Work-related MSDs, such as back and shoulder injuries, persist as the leading and most costly U.S. occupational health problem for nursing (American Nurses Association [ANA], 2009). Chronic back pain and environmental risk lead 12% to 18% of nursing personnel to leave the profession annually or to request transfer away from bedside care (Nelson & Baptiste, 2004). However, this problem is not exclusive to the nursing profession. Kneafsey, Ramsay, Edwards, and Callaghan (2012) reported that 40% of the 371 undergraduate nursing and physical therapy (PT) students surveyed admitted to performing unsafe moving and handling activities. Another 50% stated they would rather fit into the team than challenge unsafe practice (Kneafsey et al., 2012). In addition, 29% stated they had begun to experience pain since becoming a student (Kneafsey et al., 2012). The Patient Handling and Movement Assessments white paper by Cohen et al., (2010) noted a slowly growing appreciation and policy development related to safe patient handling. It is important for health care educators to recognize the risk of injury as we focus our educational approach on safety, team effectiveness, and culture change. Curricular revisions must focus student and faculty attention to personal and patient safety, considering the challenges of a more critical care environment.
Background and Significance
Received: May 29, 2014 Accepted: August 26, 2014 Posted Online: November 26, 2014 Ms. von der Lancken is Instructor, School of Nursing, and Dr. Levenhagen is Assistant Professor, Physical Therapy Program, Saint Louis University, Saint Louis, Missouri. The authors have disclosed no potential conflicts of interest, financial or otherwise. Address correspondence to Shelley von der Lancken, MSN, RN, Instructor, School of Nursing, Saint Louis University, 3525 Caroline Street, Room 329, Saint Louis, MO 63104; e-mail: [email protected]. doi:10.3928/01484834-20141118-14
704
The Handle With Care campaign was initiated by the ANA to advocate for policies to eliminate patient handling and reduce injury rates (de Castro, 2004). The campaign highlights the impact of musculoskeletal injuries on nursing professionals and suggests educational efforts to support a no-lift environment. A no-lift policy states that all manual handling tasks should be avoided whenever possible. The Patient Handling and Movement Assessments (Cohen et al., 2010) report recommends the use of equipment, although health care teams perform high-risk tasks that do not currently have safe solutions (Cohen et al., 2010). Wardell (2007) reported that despite training and sufficient equipment, 71% of the study participants did not use equipment, including slide sheets. Lee, Faucett, Gillen, and Krause (2013) surveyed critical care nurses about pain, lift availability and use, physical and psychosocial job factors, and sociodemographics. In their results, less than half (46%) of respondents reported that their employer provided lifts (Lee et al., 2013). When lifts were Copyright © SLACK Incorporated
EDUCATIONAL INNOVATIONS
available and used, a significant reduction in back and shoulder injuries resulted (Lee et al., 2013). Some health care environments provide education and safe patient handling equipment for health care providers; however, the culture and leadership in most settings has yet to make this agenda a priority. Nurses and PTs are challenged with early mobilization of an increasingly dependent, obese, and sicker patient population. Caregivers are asked to do more with less, as reimbursement for services and capital equipment have been more closely scrutinized. Thus, the patient population will require earlier mobilization, as reimbursement is increasingly tied to quality and efficiency. Research supports the significance of early mobilization to prevent postoperative complications and minimize health care–associated risks, which may create significant savings for the health care system (Cohen et al., 2010; Lewis, Dirksen, Heitkemper, Bucher, & Camera, 2011; Sarni, 2010). The challenges in the current health care environment necessitate an interdisciplinary team approach to care. Educators must revise curricula to reinforce this interprofessional relationship to include understanding the risk of injury and collaborating and advocating for an environment of safe care. In May 2013, the ANA published the Safe Patient Handling and Mobility: Interprofessional National Standards for safe patient handling. These standards provide guidelines for care settings to develop and sustain a culture of safety, including roles for all members of the health care team. Role identity, collaboration, and team effectiveness must be included in higher education to prepare students for today’s challenges. Little has been published regarding the interprofessional preparation of nursing students related to safe patient handling and movement. The purpose of this article is to describe a model promoting collaborative relationships among nursing and PT students to improve patient and caregiver safety. Through this model, the PT students teach safe patient handling skills in a simulation setting to undergraduate nursing students. In addition to learning skills, the students gain a better understanding of each other’s professional roles.
Interprofessional Collaboration Model Among Nursing and PT Students In 2006, a midwestern university initiated an interprofessional education program (IPE) as part of the core curriculum for students in nine health professional degree programs, including PT, occupational therapy, nutrition and dietetics, athletic training, and clinical laboratory science. The university’s IPE curriculum includes four interprofessional courses that allow students to accumulate 9 credit hours by the time they graduate from their professional programs. Students enroll in IPE courses at the beginning of their educational programs. The IPE curriculum includes interactive learning experiences that identify the roles of the health care team and the importance of effective teamwork. In 2009, the school of nursing and the physical therapy program expanded on the curricular theme by developing a simulated learning experience. This student-led experience includes caregiver and patient safety in an environment that fosters teamwork and respect. The faculty utilized the interprofessional Journal of Nursing Education • Vol. 53, No. 12, 2014
Figure. Interdisciplinary alliance model. From “Interprofessional Collaborative Alliances: Health Care Educators Sharing and Learning From Each Other,” by L.M. Hayward, R. DeMarco, and M.M. Lynch, 2000, Journal of Allied Health, 29, pp. 220-226. Copyright 2000 by the Association of Schools of Allied Health Professions. Reprinted with permission.
alliance model (IPAM) developed by Hayward, DeMarco, and Lynch (2000) to improve collaboration among health care professionals (Hayward et al., 2000). The Figure shows the seven phases of the IPAM. In phase I, the faculty recognized the value of collaboration on patient outcomes and caregiver safety. In phase II, a deficit in the nursing curriculum was identified that was related to safe patient handling. In addition, the PT students needed an environment in which to improve their communication skills with other health care professionals. The PT students had a strong foundation in the area of safe patient handling, making this an ideal collaborative effort. In phase III, monthly meetings identified the benefits of this collaborative experience in the curriculum. During these meetings, course objectives, evaluation criteria, and the logistics of managing the experience between two professional programs were outlined. It was determined that this interprofessional, student-led experience would develop effective team building and communication. Challenges were presented during the planning phase. The students had scheduling difficulties with other curricular requirements. In phase IV, each program made the simulation experience a priority, after recognizing the value of this professional alliance. The students had full support of faculty and quickly recognized that the collaborative effort was an incredible opportunity to affect the care and satisfaction of both students and future patients. After presenting the objectives and course plan with university administrators and the director of the IPE, the decision to commit to a formal collaborative relationship was established in phase V. Phase VI of the IPAM was the project implementation phase. The nursing students were in their third year of a 4-year baccalaureate program and were ready to begin clinical rotations for nursing care of adult and older adult patients. The PT students were in their second year of the professional phase of the Doctor of Physical Therapy program. The PT students developed objectives, a lesson plan, and handouts and provided construc705
EDUCATIONAL INNOVATIONS
TABLE 1 Course Objectives for Physical Therapy and Nursing Students Course
Overall Course Objective
Nursing
• Demonstrate clinical judgment and psychomotor skills necessary for safe and competent practice. • Communicate clearly and effectively using written, verbal, nonverbal, and technologic methods. • Utilize interprofessional communication and collaboration to provide holistic, high-quality, and safe patient care.
Physical therapy
• Value the role of feedback and self-evaluation in the process of learning. • Reflect on his or her practice, learning, and teaching of select communication skills.
Simulation learning experience led by physical therapy students
• Demonstrate bed mobility transfers with proper body mechanics, without cues. • Perform pivot transfer techniques with proper body mechanics, without cues. • Demonstrate appropriate guarding during patient ambulation with a walker, with cues less than 25% of the time. • Provide proper instruction to a patient performing a sit-to-stand transfer using a gait belt, without cues. • Recall three reasons to use proper body mechanics during safe patient-handling transfers, without cues. • Justify a selected transfer technique in a case scenario, with less than 25% cues from the physical therapy students.
tive feedback to the nursing students. Table 1 provides the overall course and PT student objectives. The PT students teaching the program started with a brief overview of the objectives and the incidence and prevalence of musculoskeletal disorders for health care providers. The PT students then provided instruction in a simulated patient care setting to teach nursing students the correct way to facilitate patient transfers, bed mobility, and gait using assistive devices. The simulated setting was housed in the physical therapy program’s laboratory, which included wheelchairs, gait belts, assistive devices, and lifts. The safe patient-handling simulation sessions provided the PT students with an opportunity to apply learning theories and to develop teaching skills. This pedagogical approach was supported by the National Institute for Occupational Safety and Health, the Veterans Health Administration, and the ANA (Waters, Nelson, Hughes, & Menzel, 2009), which advocate for safe manual handling techniques in conjunction with equipment and technology. The PT students included concepts supporting a minimal-lift and a no-lift environment as they introduced gait belts, slide boards, friction-reducing sheets, and patient assistive devices. The Egress test was included to establish nursing confidence in moving patients prior to a PT evaluation. The Egress test includes three repitions of sit-to-stand, three steps of marching in place, and advance step and return of each foot (Dionne, 2004). The nursing students mirrored the demonstration of the patient movement and transfers to validate understanding. The PT students provided feedback and a competency checklist of skills to the nursing students of their performance. Table 2 provides a list of skills performed by the nursing students. Collaboration and role identity, along with caregiver and patient safety, were priorities during the student interaction. The learning environment was comfortable, positive, and collaborative as PT students led the experience in small groups, encouraging discussion of clinical experiences. Phase VII of the IPAM invites group members to plan future research or educational efforts after a retrospective review of 706
evaluative data. The group met and decided to continue with the program and to offer additional complex care simulations that recognize the increased acuity of the patient population. In fall 2013, additional case scenarios were created for the same cohort of nursing students in their fourth year of study to build on previous experiences. The cases included patients with chronic and acute pain, partial- and nonweight-bearing status, hemiparesis, obesity, wound care, injury after a fall, postoperative activity desaturations, and hemodynamic instability. The nursing students worked in groups to discuss a plan of care for each scenario. The assignment challenged the nursing students to identify the role of each discipline in the care of the patient. The nursing and PT students then simulated safe patient handling and movement for each scenario. Strengthening the relationship and role identification is important in improving caregiver safety, workplace satisfaction, and clinical outcomes for patients. The students discussed the importance of collaboration and role identity related to patient activity and outcomes. Understanding roles and communication are important competencies for patient-centered collaborative practice (Suter et al., 2009).
Method The authors developed a study to gather feedback from the junior-year nursing students about their experience of the student-led simulation and psychomotor mastery. Following institutional review board approval, the questionnaire was distributed to the nursing students during 2009-2014 academic years by the PT students at the completion of the safe patientmovement experience. Completion of the questionnaire was voluntary, and responses were anonymous. The questions were consistent, except for 2011 in which one question was inadvertently dropped and another question was revised. Responses were based on a 4-point Likert scale (1 = strongly agree, 2 = agree, 3 = disagree, 4 = strongly disagree). The questionnaire included questions about the students’ satisfaction with the course and what they learned. Copyright © SLACK Incorporated
EDUCATIONAL INNOVATIONS
In addition, the nursing students rated their overall experience with the course. Responses for the overall experience were based on a 5-point Likert scale (1 = outstanding, 2 = above average, 3 = average, 4 = below average, 5 = very poor) and were included for all years. Descriptive statistics were calculated from the 4- and 5-point Likert scale responses. Nursing students were provided with an opportunity to write in additional comments, providing qualitative data for analysis. Written comments to open-ended questions regarding the overall perception of the course were reviewed for themes. The PT students reflected on course feedback and identified areas needing improvement in future instructional courses requiring interprofessional communication. The experience improved the PT students’ awareness regarding the significance of a work-related injury. Furthermore, the PT students did not realize that each psychomotor skill required specific instruction due to the lack of knowledge regarding safe patient handling skills in the nursing curriculum. In addition, the PT students recognized the importance of collaborative communication, as the nursing students provided new scenarios that the PT students had not experienced on previous clinical experiences. This reinforced the fact that professionals cannot work in silos but need to learn from one another to promote caregiver safety. Students from the PT program completed a reflection paper at the end to the interprofessional teaching experience demonstrating these lessons learned.
Results The number of respondents completing the questionnaires in the Nursing Care of Adults and Older Adults course were 351 (54 in 2009, 60 in 2010, 54 in 2011, 61 in 2012, 63 in 2013, and 59 in 2014). Table 3 provides feedback from the nursing students regarding the level of satisfaction of the interprofessional experience led by the PT students enrolled in the Components of Effective Communication and Teaching course. Specifically, Table 3 demonstrates that the majority of respondents strongly agreed or agreed that the course was organized, the objectives were clear, and the experience enhanced their learning. In addition, the respondents identified how confident they were in performing or understanding the skills as taught in the course. The majority (98.3%, 100%, respectively) of respondents strongly agreed or agreed that they were confident in performing or understanding the skills taught. The majority (96.2%, 100%, respectively) of respondents rated the course as outstanding or above average. Qualitative Data
Several themes emerged, which included recognizing the importance of interprofessional collaboration and the significance of the curricular addition. The students appreciated the opportunity of the simulated interprofessional experience. Some comments from the nursing students included: “It was good to work with peers [PT students], and they were very knowledgeable and straightforward, but still fun,” “Good teamwork between the groups,” “The students/teachers seemed very passionate,” and “There should be more collaboration between PT and nursing students.” Journal of Nursing Education • Vol. 53, No. 12, 2014
TABLE 2 Skills Competency Checklist Skill
Completed
Transfer up/down and side-to-side in bed: Put the bed at the correct height (waist level when providing care, hip level when moving a patient). Transfer to bed to supine to short sitting: Keep the patient as close to your body as possible to minimize reaching. Rolling: Maintain a wide, stable base with your feet. One- and two-man pivot transfer: Try to keep the load directly in front of you to avoid rotating the spine. Sit to stand Gait with walker
The nursing students recognized the importance of the experience for patient and caregiver safety and suggested that the material be provided earlier in the nursing curriculum prior to engaging in patient care. Some comments reflecting this were: “This course would be more beneficial to sophomores, before they go into their clinical setting so that they can go in feeling more confident about their patient transport skills,” and “I wish I had received this instruction earlier, I have experienced a back injury and have pain.” Reflection From PT students
At the completion of the experience, the PT students were asked to reflect on their teaching skills and their interprofessional communication with the nursing students. The importance of the collaborative relationship and role identity was acknowledged by one student’s comments: “The strength of this opportunity was integrating two health professions together, learning from each other. Even though we were the ones teaching, we learned more about the nursing students and their experiences in the clinic.”
Discussion Providing safe patient-handling education to nursing students allowed a collaborative approach to improve the delivery of high-quality, safe, and efficient care in an increasingly complex health care environment. The educational experience must shift from one in which health profession students are educated in silos to one that fosters collaboration, communication, and a team approach to providing care (Interprofessional Education Collaborative, 2011). In the current study, feedback from the students and faculty was overwhelmingly positive. In reflecting on the student evaluations, the results were similar to research by Christie, Smith, and Bednarzyk (2007). Christie et al. reported that nutrition, nursing, and PT students enjoyed learning from other disciplines and gained a better understand707
EDUCATIONAL INNOVATIONS
riers and their ability to influence practice and safety.
TABLE 3 Nursing Students’ Evaluation of the Course
Question
Question Answered (n)
The organization of this course was evident.
347
Objectives of this course were made clear at the start of the course.
347
There was agreement between the announced course objectives and what was actually taught.
347
Questioning and demonstration in class enhanced my learning.
347
The laboratory experiences were well organized.
293a
Overall, I believe I can adequately perform the skills taught in this course.
293a
Overall, I have a better understanding of back safety and transfers. a b
Question was not included in 2011 evaluation questionnaire. Question was included only in 2011 evaluation questionnaire.
ing of their respective roles when given a written case scenario. The current research demonstrates that PT students have the expertise to be mentors for nursing students in a positive and comfortable learning environment. The small groups in the current study fostered collaboration and open communication. The IPAM provided a useful model for designing curricular changes within the school of nursing and the physical therapy program. The current model has been a successful student experience and continues to improve.
Study Limitations One limitation of this study was the scheduling and availability of the students. The consistency of PT students varied due to full-time clinical placement. Scheduling issues related to laboratory space and classroom time was challenging. Another limitation was a minor change in the questionnaire in 2011. However, the students had similar responses throughout the 5 years of the program, suggesting a positive experience.
Implications for Practice and Future Research Additional areas of research include the use of questionnaires concerning the availability of equipment, interprofessional collaboration, and the support in health care environments for safe patient handling and movement policies. Furthermore, the authors plan to use previously obtained student data to determine whether the experiences have changed the students’ attitudes and perceptions about working in collaborative teams. Surveys of the graduates, who are now in practice settings, will also be a key component of this initiative to identify environmental bar708
The current study education model that included simulation and safe patient 344 (99.1) 3 (0.9) handling was a valuable addition to the curriculum. Higher education curricula 346 (99.7) 1(0.3) must include collaboration in clinical or simulated care set345 (99.4) 2 (0.6) tings to address the complex care needs of patients and to improve team effective345 (99.4) 2 (0.6) ness (Suter et al., 2009). The IPAM model has reinforced 289 (98.6) 4 (1.4) the significance of this collaborative relationship, along 292 (99.7) 1 (0.3) with enhancing role identity for student participants. This 54 (100) 0 (0) model helps the students to understand their own roles and those of the health care team so that each member can work together in a respectful and inclusive environment (Ateah et al., 2011). Curricular modifications must emphasize the importance of a culture change in health care. Training of health care professionals can no longer occur in silos as we prepare our students to not approach care as individual experts but as expert teams.
Strongly Agree/ Agree (n, %)
54b
Conclusion Disagree/ Strongly Disagree (n, %)
References American Nurses Association. (2009). ANA supports safe patient handling measures in congress to improve safety of nurses and patients. Retrieved from http://safeliftingsolutions.com/docu/safe.pdf American Nurses Association. (2013). Safe patient handling and mobility: Interprofessional national standards. Silver Spring, MD: Author. Ateah, C.A., Snow, W., Wener, P., MacDonald, L., Metge, C., Davis, P., . . . Anderson J. (2011). Stereotyping as a barrier to collaboration: Does interprofessional education make a difference? Nurse Education Today, 31, 208-213. doi:10.1016/j.nedt.2010.06.004 Christie, C., Smith, A.R., Jr., & Bednarzyk, M. (2007). Transdisciplinary assignments in graduate health education as a model for future collaboration. Journal of Allied Health, 36, 67-71. Cohen, M.H., Nelson, G.G., Green, D.A., Leib, R., Matz, M.W., & Thomas, P.A. (2010). Patient handling and moving assessments: A white paper. Retrieved from http://www.fgiguidelines.org/pdfs/FGI_PHAMA_ whitepaper_042810.pdf de Castro, A.B. (2004). Handle with care®: The American Nurses Association’s campaign to address work-related musculoskeletal disorders. The Online Journal of Issues in Nursing, 9(3), Manuscript 2. Dionne, M. (2004). Introducing the egress test, A simple screening tool to predict safety of bariatric patients transfers. Advance Physical Therapists and PT Assistants, 15(13), 39-40. Hayward, L.M., DeMarco, R., & Lynch, M.M. (2000). Interprofessional collaborative alliances: Health care educators sharing and learning from each other. Journal of Allied Health, 29, 220-226. Interprofessional Education Collaborative. (2011). Team-based competencies: Building a shared foundation for education and clinical practice
Copyright © SLACK Incorporated
EDUCATIONAL INNOVATIONS
[Conference proceedings]. Washington, DC: Author. Retrieved from http://www.aacn.nche.edu/leading-initiatives/IPECProceedings.pdf Kneafsey, R., Ramsay, J., Edwards, H., & Callaghan, H. (2012). An exploration of undergraduate nursing and physiotherapy students’ views regarding education for patient handling. Journal of Clinical Nursing, 21, 3493-3503. doi:10.1111/j.1365-2702.2012.04172.x Lee, S.J., Faucett, J., Gillen, M., & Krause, N. (2013). Musculoskeletal pain among critical-care nurses by availability and use of patient lifting equipment: An analysis of cross-sectional survey data. International Journal of Nursing Studies, 50, 1648-1657. doi:10.1016/j. ijnurstu.2013.03.010 Lewis, S.L., Dirksen, S.R., Heitkemper, M.M., Bucher, L., & Camera, I. (2010). Medical-surgical nursing: Assessment and management of clinical problems (8th ed.). St. Louis, MO: Elsevier Mosby. Nelson, A., & Baptiste, A.S. (2004). Evidence-based practices for safe patient handling and movement. The Online Journal of Issues in Nursing, 9(3), Manuscript 3.
Journal of Nursing Education • Vol. 53, No. 12, 2014
Sarni, N. (2010). A short walk a day shortens the hospital stay: Physical activity and the demand for hospital services for older adults. Canadian Journal of Public Health, 101, 385-389. Suter, E., Arndt, J., Arthur, N., Parboosingh, J., Taylor, E., & Deutschlander, S. (2009). Role understanding and effective communication as core competencies for collaborative practice. Journal of Interprofessional Care, 23, 41-51. doi:10.1080/13561820802338579 U.S. Department of Labor, Bureau of Labor Statistics. (2013). Nonfatal occupational injuries and illnesses requiring days away from work, 2012 [Press release]. Retrieved from http://www.bls.gov/news.release/osh2. nr0.htm Wardell, H. (2007). Reduction of injuries associated with patient handling. American Association of Occupational Health Nurses Journal, 55, 407412. Waters, T., Nelson, A., Hughes, N., & Menzel, N. (2009). Safe patient handling training for schools of nursing: Curricular materials. North Charleston, NC: CreateSpace.
709
