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Safe Patient Handling Perceptions and Practices: A Survey of Acute Care Physical Therapists

Brian F. Olkowski, Angela M. Stolfi
DOI: 10.2522/ptj.20120539 Published 1 May 2014

This article has a correction. Please see:

Abstract

Background Acute care physical therapists are at risk for developing work-related musculoskeletal disorders (WMSDs) due to manual patient handling. Safe patient handling (SPH) reduces WMSDs caused by manual handling.

Objective The purpose of this study was to describe the patient handling practices of acute care physical therapists and their perceptions regarding SPH. Additionally, this study determined whether an SPH program influences the patient handling practices and perceptions regarding SPH of acute care physical therapists.

Methods Subscribers to the electronic discussion board of American Physical Therapy Association's Acute Care Section were invited to complete a survey questionnaire.

Results The majority of respondents used SPH equipment and practices (91.1%), were confident using SPH equipment and practices (93.8%), agreed that evidence supports the use of SPH equipment and practices (87.0%), and reported the use of SPH equipment and practices is feasible (92.2%). Respondents at a facility with an SPH program were more likely to use SPH equipment and practices, have received training in the use of SPH equipment and practices, agree that the use of SPH equipment and practices is feasible, and feel confident using SPH equipment and practices.

Limitations The study might not reflect the perceptions and practices of the population of acute care physical therapists.

Conclusion Acute care physical therapists are trained to use SPH equipment and practices, use SPH equipment and practices, and have positive perceptions regarding SPH. Acute care physical therapists in a facility with an SPH program are more likely to use SPH equipment and practices, receive training in SPH equipment and practices, and have positive perceptions regarding SPH. Quasi-regulatory organizations should incorporate SPH programs into their evaluative standards.

According to the US Department of Labor's Bureau of Labor Statistics, health care occupations rank among those professions with the highest incidence of work-related musculoskeletal disorders (WMSDs) and days away from work resulting from a WMSD.1 Physical therapists are susceptible to WMSDs, and some studies have suggested that up to 90% of physical therapists have experienced a WMSD.2–7 The 1-year work-related injury incidence rate for physical therapists is 20.7%.6 Unfortunately, the high incidence of WMSDs has resulted in many physical therapists either changing their practice setting or leaving the profession entirely.7,8

In acute care hospitals, manual patient handling has resulted in a high incidence of WMSDs among health care providers.9 Acute care physical therapist practice includes the manual handling of patients with complex medical conditions in a complex environment.10,11 In addition, the patient repositioning and transferring activities frequently used by acute care physical therapists were found to be hazardous to health care providers.12–14 The types of interventions used by acute care physical therapists, along with the complexity of the patient population and environment, place acute care physical therapists at risk for experiencing a WMSD.

Fortunately, safe patient handling (SPH), that is, the use of assistive equipment to reduce manual patient handling, has been shown to reduce WMSDs among health care providers.15–17 Legislators and professional organizations have recognized the importance of SPH. Eight states (California, Illinois, Maryland, Minnesota, New Jersey, Rhode Island, Texas, and Washington) have enacted legislation mandating SPH programs in health care facilities.18 Although some variability exists in the enacted SPH legislation, all states require staff training in the use of SPH equipment and practices and the development of an SPH policy.19–26 The major components of the enacted SPH legislation are summarized in Table 1.

View this table:
Table 1.

Comparison of the Major Components of Enacted Safe Patient Handling Legislation

A recent collaboration of the professional organizations of health care providers primarily involved in patient handling, including the American Physical Therapy Association (APTA), has resulted in the development of national SPH standards. The standards recommend the development of SPH programs at all health care facilities to reduce the incidence of WMSDs among health care providers.27 As part of their SPH program, health care facilities would purchase SPH equipment, train health care providers in the use of SPH equipment and practices, and continually evaluate the effectiveness of the SPH program.27

The APTA has previously supported the use of SPH equipment and practices28 and recently issued a position statement on the role of physical therapist in SPH. The position envisions physical therapists and physical therapist assistants as leaders in the development, implementation, refinement, and maintenance of SPH programs on an institutional level and at the local, state, and federal government levels.29 In addition, APTA supports the use of SPH equipment and practices by physical therapists and physical therapist assistants during patient care and the expansion of SPH knowledge of the multidisciplinary health care team.29

Some physical therapists have been reluctant to adopt SPH practices because they believe that WMSDs caused by manual patient handling can be prevented with correct lifting techniques.30 In addition, rehabilitation professionals, including physical therapists, have reported that the design of standard SPH equipment does not facilitate patient participation in functional training and may result in functional decline and loss of independence.31,32 Recent studies have focused on the influence of SPH on physical therapy practice and patient outcomes. The use of SPH equipment and practices has resulted in similar or even slightly better mobility outcomes compared with the outcomes of patients treated without SPH equipment and practices.33 Physical therapists using SPH equipment and practices reported a reduction in fatigue, allowing earlier and more frequent patient mobilization in patients with lower functioning for longer periods of time.34

As the use of SPH equipment and practices becomes more prevalent in health care facilities, the handling practices of acute care physical therapists should be examined. Although we anticipate that the majority of acute care physical therapists have used SPH equipment and practices, we were interested in answering the following questions:

  1. Why do acute care physical therapists use SPH equipment and practices, and what limits their use?

  2. Who trains acute care physical therapists in the use of SPH equipment and practices?

  3. Which types of SPH equipment are used by acute care physical therapists, and during which interventions are they used?

  4. What are acute care physical therapists' perceptions regarding the use of SPH equipment and practices?

In addition, we hypothesized that many acute care physical therapists, especially those practicing in a state with a legislative mandate, would have an SPH program at their facility. Because SPH programs generally include training in the use of SPH equipment and practices,19–27 we propose that the presence of an SPH program would have a positive influence on acute care physical therapist practice.

Our study had 2 purposes: (1) to describe the current patient handling practices of acute care physical therapists and their perceptions regarding SPH and (2) to determine whether the presence of an SPH program influences the patient-handling practices of acute care physical therapists and their perceptions regarding SPH.

Method

Survey and Participants

A 24-question electronic survey questionnaire (Appendix) was developed by 2 content experts (B.F.O., A.M.S.) according to Dillman and colleagues' method.35 Three questions utilized conditional branching in which a respondent bypassed predetermined questions depending on the answer to a corresponding question. The survey questionnaire included questions regarding respondents' sociodemographic characteristics, use of SPH equipment and practices, and training in the use of SPH equipment and practices. Because relatively few studies have examined the feasibility of using SPH equipment and practices and the effects on patient outcomes,33,34 the survey questionnaire included questions regarding the feasibility of using SPH equipment and practices in acute care, the adequacy of evidence supporting the use of safe patient-handling equipment and practices, and the influence of safe patient-handling equipment and practices on the quality of physical therapy.

A convenience sample of 10 acute care physical therapists from 5 states was used for pilot testing. Psychometric testing was performed for test-retest reliability on questions determining current SPH practices (intraclass correlation coefficient=.698) and internal consistency on questions determining physical therapist perceptions regarding SPH (α=.701). Pilot testing resulted in minor changes to the language and layout of the survey questionnaire. The results of pilot testing determined that content and face validity were adequate.

Respondents to the survey questionnaire were members of the Acute Care Section of APTA who reported practicing physical therapy in acute care. The Communications Committee of the Acute Care Section granted permission for the investigators to solicit participation from the Section's electronic discussion board. Subscribers to the electronic discussion board are required to be members of APTA and the Acute Care Section. An invitation to participate in the study and a web link to the survey questionnaire were posted on the Section's electronic discussion board. The invitation identified the following: purpose of the study, principal investigators, operational definition of SPH, and the process of informed consent.

Subscribers were allowed 30 days to complete the survey questionnaire. The web link to the survey questionnaire was inactivated after the data collection period. A reminder message was posted on the Section's discussion board before the web link was inactivated. The submission of a completed survey questionnaire signified informed consent to participate in the study. SurveyMonkey (SurveyMonkey LLC, Palo Alto, California, http://www.surveymonkey.com), a commercial online survey system, was used to administer the survey questionnaire and collect data. The Checklist for Reporting Results of Internet E-Surveys (CHERRIES) was used to ensure the quality of reporting the findings of this study.36

Data Analysis

IBM SPSS, version 20.0, (IBM Corp, Armonk, New York) was used for all statistical analyses. Descriptive statistics were used to summarize the distribution, central tendency, and dispersion of respondents' responses to the survey questionnaire. A bivariate analysis using the chi-square test was conducted to determine the influence formal SPH programs had on respondents' patient handling practices, formal training in the use of SPH equipment and practices, and perceptions regarding SPH. In addition, the chi-square test was used to determine whether there was an association between the presence of a formal SPH program and whether the facility was in a state with enacted SPH legislation. P values of less than .05 were accepted as having a significant association or difference.

Results

There were 880 subscribers to the Acute Care Section's electronic discussion board at the time of the invitation to participate in the study (June 28, 2012). One hundred ninety-two respondents completed the survey questionnaire (21.8% response rate). Three partially completed surveys contained demographic information only and were not included in the results. The majority of respondents were female (79.2%), and the average age was 44.0 years.

Thirty-four respondents (17.7%) held American Board of Physical Therapy Specialties (ABPTS) certification, and 49 respondents (25.5%) practiced physical therapy in a state with enacted SPH legislation. Respondent demographic characteristics are described in Table 2.

View this table:
Table 2.

Respondent Demographics (N=192)a

Patient Handling Practices

Of the 192 respondents surveyed, 175 (91.1%) reported that they use SPH equipment and practices during physical therapy sessions. These respondents were asked about the following: their reasons for using SPH equipment and practices, the interventions when they used SPH equipment and practices, the types of SPH equipment used during physical therapy sessions, and factors that limited their use of SPH equipment and practices. Results are shown in Table 3.

View this table:
Table 3.

Safe Patient Handling (SPH) Practices of Acute Care Physical Therapists (n=175)a

Respondents reported on their participation in SPH-related activities at their facilities. One hundred sixty-two respondents (84.4%) reported that they had participated in SPH activities at their facility. These activities included: education or training other health care providers in the use of SPH equipment or practices (89.5%), participation in an SPH committee or program (56.8%), evaluation of SPH equipment for use or purchase (56.8%), and development of SPH policy or practice (39.5%).*

Safe Patient Handling Training

Respondents were asked about their training in the use of SPH equipment and practices. One hundred seventy-one respondents (89.1%) reported having received formal training in the use of SPH equipment and practices (Tab. 4). Respondents reported receiving training from the following sources: facility or employer (91.8%), physical therapy school (45.0%), and continuing education programming (39.2%).*

View this table:
Table 4.

Characteristics of All Respondents and by the Presence of a Formal Safe Patient Handling (SPH) Program at Respondent's Facilitya

Safe Patient Handling Perceptions

All respondents were asked their level of agreement with several statements regarding the use of SPH equipment and practices (Tab. 5). Overall, respondents had positive perceptions about the use of SPH equipment and practices.

View this table:
Table 5.

Perceptions Regarding Safe Patient Handling (SPH) of All Respondents and Presence or Absence of a Formal Safe Patient Handling Program at Respondents' Facilitya

Twenty-two respondents either agreed or strongly agree that the quality of physical therapy is diminished by the use of SPH equipment and practices. These respondents reported their agreement for the following reasons: reduced active patient participation (77.3%), reduced ability of therapist to provide training (68.2%), reduced intervention time (40.9%), and negative patient perceptions (27.3%).*

Safe Patient Handling Programs

One hundred thirty-seven respondents (71.4%) reported having a formal SPH program at their facility. Respondents practicing at a facility with a formal SPH program were more likely to use SPH equipment and practices during physical therapy sessions (P=.020) and have received training in the use of SPH equipment and practices (P=.000). Interestingly, facilities in states with enacted SPH legislation were not any more likely to have an SPH program than facilities in states without a legislative mandate (P=.630). Results are shown in Table 4. In addition, respondents practicing at a facility with a formal SPH program were more likely to agree that the use of SPH equipment and practices was feasible during physical therapy sessions (P=.029) and were more confident in their ability to use SPH equipment and practices (P=.001). Results are shown in Table 5.

Discussion

Role of the Acute Care Physical Therapist

Acute care physical therapists frequently determine the most appropriate handling method for both the patient and health care provider to begin rehabilitation. The results of our study suggest that in addition to using SPH equipment and practices, acute care physical therapists train other health care providers in the use of SPH equipment and practices, participate in SPH programs, evaluate SPH equipment for use or purchase, and develop SPH policy and practice at their facilities. Our findings have identified the importance of the physical therapist to SPH in acute care and are consistent with the role of the physical therapist in SPH supported by APTA.29

Safe Patient Handling Training

The majority of acute care physical therapists reported that they received training in the use of SPH equipment and practices from their employer or facility. Several respondents commented that the training was conducted by representatives of the SPH equipment manufacturers. Interestingly, only 45% of the respondents reported receiving training on SPH equipment and practices from their physical therapy program. Although the Commission on Accreditation in Physical Therapy Education (CAPTE) requires physical therapy programs to incorporate evidence-based practice into their curriculum, there are no curriculum content requirements for professional (entry-level) physical therapist programs to educate and train students in the use of SPH equipment and practices or the prevention of WMSDs.37 We recommend that CAPTE incorporate the education and training of physical therapist students on the use of SPH equipment and practices into their evaluative criteria for physical therapist programs because the use of SPH equipment and practices has been shown to reduce WMSDs.16–18

Influences on Patient Handling Practices

Acute care physical therapists have identified a variety of factors that influence their decision to use SPH equipment and practices. Not surprisingly, the majority of respondents reported using SPH equipment and practices to improve patient and health care provider safety and improve the quality of their interventions (Tab. 3). The most frequently reported factor limiting the use of SPH equipment and practices was a lack of equipment, a potential a reason some states (Minnesota, New Jersey, and Washington) have incorporated equipment requirements into their SPH legislation. The least frequently reported reason for using SPH equipment and practices was because of a legislative mandate. The results of our study suggest that safety and quality are important factors that influence the decision of the acute care physical therapist to use SPH equipment and practices.

The results of our study indicate that acute care physical therapists who practice in a facility with an SPH program were more likely to use SPH equipment and practices during physical therapy sessions, have received training in the use of SPH equipment and practices, agree that the use of SPH equipment and practices was feasible during physical therapy sessions, and were more confident in their ability to use SPH equipment and practices. Although the implementation of SPH programs requires financial and logistical resources, the professional organizations of health care providers primarily involved in patient handling have identified that SPH programs are necessary in establishing a culture of safety for both patients and health care providers.27

Interestingly, our study also showed that facilities in states with enacted SPH legislation were not any more likely to have an SPH program than facilities in states without a legislative mandate. Although there are similarities in the enacted SPH legislation, some variability exists. For example, an SPH committee is required in only 5 of the 8 states with enacted SPH legislation, and Texas mandates that only nurses need to be trained in the use of SPH equipment and practices (Tab. 1). Health care facilities have reported that they rely more on the standards of quasi-regulatory organizations, private purchasers, professional organizations, and federal agencies than on state legislative mandates to improve health care safety.38 The use of SPH equipment and practices might become more prevalent in health care facilities if quasi-regulatory organizations (eg, The Joint Commission), private purchasers (eg, The Leapfrog Group), and federal agencies (eg, the Agency for Healthcare Research and Quality) incorporate the implementation of SPH programs into their evaluative standards.

Future Directions

As the use of SPH equipment and practices becomes more prevalent in acute care, its impact on the delivery of physical therapy and patient outcomes should be evaluated. Acute care physical therapists reported using various types of SPH equipment to facilitate patient mobilization (Tab. 3), which might differ from the types of equipment used by other health care providers. Further investigation might identify how acute care physical therapists use SPH equipment and practices to enhance patient rehabilitation so that these practices can be utilized by a wider range of health care professionals.

In addition, our study was not designed to identify common patient populations in which acute physical therapists typically use SPH equipment and practices. The identification of specific patient populations with whom SPH equipment is most likely to be used might allow equipment to be made available in the areas of highest need, potentially addressing some of the most common barriers to using SPH equipment and practices identified in our study (lack of equipment, productivity requirements).

Acute care physical therapist practice includes frequent interactions with other health care providers, such as nurses, whose professions may have already adopted the use of SPH equipment and practices. The perceptions of other health care providers were identified in our study as contributing to the patient handling practices of acute care physical therapists (Tab. 3). In addition, enacted SPH legislation has primarily mandated the use of SPH equipment and practices in acute care hospitals and nursing homes.19–26 Further investigation might identify the influence practice setting and other health care providers have on the patient handling practices and perceptions regarding SPH of physical therapists.

Limitations

The primary limitation of our study was that selection bias might have diminished the generalizability of the perceptions and practices of the respondents. Our study design did not provide all members of the Acute Care Section the opportunity for inclusion, potentially introducing coverage error. In addition, subscribers to the Acute Care Section's electronic discussion board were not mandated to participate in the study, raising the possibility that subscribers with an interest or experience in SPH may have been more likely to complete the survey questionnaire (voluntary response bias). Conversely, subscribers without an interest or experience in SPH might not have chosen to participate in the study (nonresponder bias).

All respondents subscribed to the Acute Care Section's electronic discussion board, suggesting that they have made a commitment to their professional education and competency and potentially introducing a bias resulting in a group of respondents with qualities that differed from the entire population of acute care physical therapists.

Although our study identified respondents using SPH equipment and practices because of a WMSD, we failed to identify respondents with a WMSD who did not use SPH equipment and practices. These data could have allowed the comparison of handling practices among respondents based on the presence of a previous WMSD, potentially identifying the significance of a previous WMSD on patient handling practices and perceptions regarding SPH. Despite the limitations, our study provides a valuable insight into the current patient handling practices of acute care physical therapists and their perceptions regarding SPH.

Conclusion

The results of our survey suggest that acute care physical therapists have been trained in the use of SPH equipment and practices, use several types of SPH equipment during a variety of interventions, and have positive perceptions regarding SPH. Acute care physical therapists were found to train other health care providers in the use of SPH equipment and practices, participate in SPH programs, evaluate SPH equipment for use or purchase, and develop SPH policy and practices at their facilities.

Interestingly, acute care physical therapists practicing in a facility with an SPH program are more likely to use SPH equipment and practices, receive training in SPH equipment and practices, feel confident using SPH equipment and practices, and feel the use of SPH equipment and practices is feasible. Quasi-regulatory organizations, such as The Joint Commission, should incorporate the implementation of SPH programs into their evaluative standards.

Footnotes

  • Both authors provided concept/idea/research, writing, and data collection and analysis. Dr Olkowski provided project management. Dr Stolfi provided consultation (including review of manuscripts before submission). The authors thank the members of APTA's Acute Care Section for their participation in this study.

  • The study was approved by the Capital Health Institutional Review Board.

  • ↵* Not mutually exclusive. Results not represented in a table.

  • Received January 2, 2013.
  • Accepted February 21, 2014.

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Safe Patient Handling Perceptions and Practices: A Survey of Acute Care Physical Therapists
Brian F. Olkowski, Angela M. Stolfi
Physical Therapy May 2014, 94 (5) 682-695; DOI: 10.2522/ptj.20120539

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Safe Patient Handling Perceptions and Practices: A Survey of Acute Care Physical Therapists
Brian F. Olkowski, Angela M. Stolfi
Physical Therapy May 2014, 94 (5) 682-695; DOI: 10.2522/ptj.20120539
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