Safe Patient Handling Education in Nepal: A Canadian Perspective in Creating and Conducting Training in a Developing Country

Abstract

Background:

Safe patient handling (SPH) and positioning is a worldwide health care issue in both developed and developing countries. It is important for all caregivers and patients but especially for palliative care and oncology patients. While there is a wide breadth of curriculum available in developed countries, little information is available about how to teach SPH and positioning in a developing country where resources are very limited.

Objective/Methodology:

This article describes the process and recommendations used by a Canadian multidisciplinary health professional team in developing SPH curriculums for palliative care communities in Nepal. Educational materials were developed to teach SPH to a group of health care professionals at a palliative care conference in Bhaktapur, Nepal, in addition to a number of other settings within the Kathmandu Valley area.

Results:

Current barriers toward future development of SPH in Nepal are defined and discussed. The SPH curriculums that have been created are provided and specific recommendations are outlined. There is a dearth of research to guide SPH education in developing countries. SPH change requires long-term support and curriculums that are culturally sensitive and contextually appropriate.

Introduction

Safe patient handling (SPH) is an international concern. Patient handling is defined as the use of manual techniques or equipment to move a dependent person.¹ Health professionals, family members, and other caregivers who are helping physically move or position patients are at high risk for injuries. SPH and positioning is of utmost importance in the palliative care and oncology populations, who have fluctuating physical abilities, weakened muscles, poor activity endurance, and potentially compromised skin integrity. There are many studies that have examined SPH from different perspectives within the context of the health care systems of developed countries. Research has shown that patient handling is a dangerous task.^1–15 However, there is a dearth of literature about how to teach and promote SPH in a developing country where risks of injury may be even higher due to lack of resources and unfavorable conditions.

The United States Bureau of Labor and Statistics reported that hospitals had more overexertion injuries than any other industry.³ The most common reported injuries from patient handling are low back pain and shoulder injuries.^1,4,8,15 It has been estimated that approximately 12% of nurses leave the clinical nursing profession because of back pain. Injuries are reported by greater than 52% of nurses,⁶ and have resulted in immense work absences, injury claims, workers' compensation costs, and medical treatment costs.^6,7 Unsafe patient handling for caregivers results in increased absenteeism and organizational disruptions that make follow-through on care plans and practice improvements difficult.^4,7 Unsafe patient handling and positioning can also lead to adverse events and injuries for patients resulting in increased medical related costs, need for more caregiver support, and need for specialized equipment.^2,14 Unsafe practices impact patient comfort, fear, pain, and dignity. It can result in shoulder injuries, fractures, bruising, skin tears, and pressure damage that can further decrease a patient's independence and comfort.

Considering the immense impacts of unsafe patient handling, as measured in developed countries, there have been many efforts to develop best practices.^{1,2,12,14,16–18} However, there is little agreement in literature about how to create effective SPH curriculums and environments. In a review of evidence-based SPH practice, Nelson and Baptiste² delineated best practices into three areas: engineering controls, administrative controls, and behavioral/work practice controls.

Engineering controls include the use of equipment and have shown a strong capacity to reduce injuries among caregivers and patients.^{2–4,16–17} Equipment studied in research includes both electronic and nonelectronic devices such as lateral transfer boards, patient lifters, adjustable beds, gait belts, and friction-reducing slider sheets. While the use of equipment has been shown to decrease injuries, there are barriers to using equipment in some settings that include a lack of available and appropriate equipment and a lack of cultural acceptance.^2,5,13,16 Effective engineering controls need to be combined with administrative controls in which the management of the health care setting sets policies for SPH. Administrative policies, such as “no-lift policies,” are viewed as an agreement between caregivers and management to be involved in maximizing safety. Administrative controls aim to create a culture of SPH.¹⁴ Like the use of equipment, it is not easy to implement these policies in every setting where SPH is required.^4,13 The last area for improving SPH, behavioral and work practice controls, includes teaching professional and family caregivers the importance of ergonomics, encouraging safe patient participation, and the use of transfer algorithms.^{2,4,5,12,16,18} Training promotes the use of safe procedures and attempts to reduce unsafe practices. It includes teaching a critical observation and problem-solving approach to maximize patient active involvement while also keeping the patient and caregiver safe.^10,12 Education methods of peer coaching, train-the-trainer, and simulated training are often used.

Most SPH research and best practice development has been completed in developed countries and generally shows SPH programs decrease patient and caregiver injuries, injury costs, and lost productivity days.^4,19 There is a scarcity of research that looks at SPH education and evidence-based practices that align with the social, physical, economic, and cultural environments of developing countries. It is not known if the current SPH programs and research completed in developed nations is transferable to developing countries.

Assuming that patients and caregivers in developing countries are also at risk for injury during patient handling, it is important to examine SPH practices in developing countries and to identify existing barriers to safe practice. This article describes the development and implementation of a SPH education course for nurses working in palliative care units and hospices in the Kathmandu Valley area of Nepal. Barriers and needs for future development are examined.

Methodology and Results

During the fall of 2010 a multidisciplinary team from Nanaimo, British Columbia, Canada, traveled to Bhaktapur, Nepal, and the surrounding area. The trip was arranged through the local organization Partners in Compassion²⁰ that has formed a twinning partnership between the palliative care community in Nanaimo and the Bhaktapur Cancer Hospital. The goal of the twinning project has been to form a mutually beneficial collaboration between the two palliative care communities where the practice of palliative care and the quality of life for palliative patients and their caregivers is enhanced in both Nepal and Canada. The Partners in Compassion website²⁰ displays resources, values, goals, and practicalities of the twinning project initiative, providing a model for other hospices in developed countries that want to initiate similar twinning projects.

A major goal of all the educational trips has been to provide support and information that was identified as important by the palliative care health professionals in Nepal. All Partners in Compassion education initiatives aim to provide practical training and materials that enable the Nepalese palliative care community to become self-sustaining, with constant consideration of the limited available resources in Nepal. One of the identified teaching areas for the 2010 inter-disciplinary trip was to develop and implement a SPH course. The timeline to do this included three phases: preparation prior to travel; refinement and conduction of SPH curriculum; and follow-up after teaching was completed (Table 1). For the three phases an interdisciplinary team of health professionals was utilized (Table 2).

Table 1.

Safe Patient Handling Teaching Events

Preparation before travel to Nepal	• Reviewed current SPH literature and resources
	• E-mail discussion and reviewed pictures with staff at the Nepal palliative care unit regarding clothing, equipment, customs and current practice
	• Discussion and planning with Canadian staff from previous travels
	• Long form of curriculum created including picture based PowerPoint presentation slides and videos
	• Collected basic equipment to donate to palliative care sites in Nepal (walkers, slider/draw sheets)
	• Nepalese hospital staff started to organize palliative care conference
Work during time in Nepal	• One-week clinical care observations of palliative care unit
	• Flexible conference and travel teaching schedule formed
	• Small group learning opportunities formulated
	• Developed short-form presentation to highlight key points
	• Long-form of presentation refined based on observations
	• SPH sessions taught at conference and travel teaching sessions
Follow-up after travel concluded	• Ensured all palliative/hospice care units visited had a copy of the SPH presentation tools and website address
	• Posted presentation tools and videos on website
	• Provided curriculum to Canadian nurses going on a later trip to review with Nepalese nurses

SPH, safe patient handling.

Table 2.

Interdisciplinary Team and Roles

Occupational therapist and physiotherapist	• Developed and refined SPH curriculum
	• Observed and provided hands-on clinical assist of SPH tasks in palliative care unit
	• Arranged donated equipment that would assist with SPH in Nepal
	• Provided lecture style and hands-on SPH training;
	• Ensured copies of curriculum available to Nepalese palliative care professionals
Kinesiologist	• Consulted regarding the ergonomics of curriculum
	• Collected donated equipment that would assist with SPH in Nepal
	• Assisted during hands-on practical SPH sessions
Registered nurse	• Observed and provided hands-on clinical assist of SPH tasks in palliative care unit
	• Answered questions during SPH lectures specifically related to nursing care activities
	• Assisted during hands-on practical SPH sessions

SPH, safe patient handling.

Preparation prior to travel

Prior to leaving for Nepal a large part of the SPH and positioning curriculum was developed. The curriculum was created based on literature,²¹ professional training and experience, online resources, videos,²² and discussions with health care professionals who had been on previous trips to Nepal. While many of these resources had valuable information, none of the sources provided an educational tool that would address the needs of an education program for a developing country. The goals of the curriculum were to teach SPH that maintained the safety of both the caregiver and the patient, to maximize safe patient involvement, and to provide information regarding patient positioning for comfort and skin integrity. Prior to leaving for Nepal, the curriculum was pilot tested with Canadian nursing students. The SPH curriculum was based on principles (Table 3) as follows: plain, easily understood English, videos, demonstrations, hands-on teaching, student participation, and review of concepts.

Table 3.

Principles Incorporated into Making Effective Teaching Curriculum

Incorporate multiple learning styles	• Auditory (presentation)
	• Visual (picture based PowerPoint; videos)
	• Kinesthetic (hands-on simulated practice; participants encouraged to be both the caregiver role and patient role)
Easy and plain language	• Presentation reviewed and critiqued by Canadian nursing students and Canadian OT/PT colleagues
	• Jargonistic language removed
	• Picture-based presentation; words complimented pictures
Cultural appropriateness	• Conservative clothing worn in pictures, videos, and lectures
	• Nepalese nurses given hierarchical role as teachers of SPH
	• Provided options for equipment substitutions
	• Awareness of equipment resource limitations in Nepal
Problem-solving approach	• Teaching of analytical skills in SPH;
	• Incorporates the use of ergonomics and low-technology equipment options (ex: belts, scarves, sheets).
Flexibility	• Observation of current patient handling
	• Discussion with Nepalese staff about current practices
	• Flexibility and refinement of curriculum to meet the needs of the Nepalese patients, staff, and environment while maintaining safety

OT, occupational therapy; PT, physical therapy.

A significant goal in developing a culturally sensitive curriculum was to present the information in a way that was meaningful to the nurses within the culture of the Nepalese health system. The Nepalese health system is highly integrated with family participation. Families do most of the daily and personal care for the patients leaving the nurses to tend to the patients' medical needs. Previously, Canadian nurses and doctors who travelled to the area found that nurses were more open to the SPH education when they assumed an educator role with families. The curriculum was introduced as something the nurses needed to know in order to teach families how to better care for the patients. This acknowledgement of the structure of the Nepalese system was found to be crucial to meaningful and effective teaching that was subsequently accepted by the Nepalese health professionals.

The curriculum focused on teaching a problem-solving approach in which the caregiver used analysis of the patient and environment in order to choose a safe technique and patient transfer style. Prehandling assessment and ergonomics were included as a vital part of each patient-handling encounter. An analytical problem-solving educational approach was chosen in order to encourage the Nepalese nurses to become self-sufficient in assessing safe and unsafe practices.

An analysis of limited resources in Nepal indicated that the curriculum would need to focus on an ergonomic and problem-solving approach as opposed to the technology perspective. SPH techniques had to incorporate nonadjustable beds and situations in which patients had to sleep on the floor. Innovative ideas of using scarves and pant belts instead of medical transfer belts were also included in the curriculum. A few items were brought to Nepal to aid in teaching the curriculum: paper manuals of the presentation; a laptop computer; USB memory sticks; 6 two-wheeled walkers, and approximately 20 friction-reducing slider-sheets.

Refinement and conduction of SPH curriculum

Initial analysis of current patient handling practices found that families tended to complete a majority of patient handling tasks. Often the patients were being lifted under the arms or by the limbs to assist them to roll over or get on or off the bed. During these transfers, patient facial wincing and grimacing was often observed and during one observed transfer the patient was almost dropped. One patient's wife reported that she was experiencing back pain from assisting her husband. Based on observation of the palliative care unit in Nepal and through consultation with the staff, patients and families at the unit, the SPH curriculum was refined and the shorter SPH session was developed to focus on key issues. A 2-week palliative care conference was organized at the Bhaktapur Cancer Clinic with more than 40 participants from the Kathmandu Valley area including doctors, nurses, and a social worker. The conference included a full-day course in SPH, comprising a morning classroom-based informational session focusing on key points of SPH and positioning and an afternoon of hands-on simulated practice. The morning session was conducted in the hospital conference room using a multimedia presentation and demonstrations. The afternoon session was completed in the hospital outdoor courtyard where four hospital beds were moved for simulated practice. Smaller groups of participants also attended a shorter morning session focusing on key points of SPH and positioning that was conducted multiple mornings during the conference. This shorter session was also conducted as a traveling education class for two hospice facilities and one hospital oncology/palliative care unit in the Kathmandu Valley. In all sessions, contextual and practical teaching techniques and hands-on, kinesthetic learning were utilized in practice simulations. Participants were encouraged to be both the caregivers and patients in simulations to enhance an understanding of patient comfort for SPH.

Follow-up after teaching completed

While formal measurement of the effectiveness of the teaching was not completed, there were informal observations of increased learning of SPH techniques. During the hands-on training the Nepalese nurses began to teach each other, provide critical analysis of each other's SPH techniques, and were able to demonstrate techniques during practical sessions that would keep both themselves and the patient safe.

After teaching was completed, the therapists ensured that each site had a paper copy of the curriculum tools. Copies of slides and handouts were later posted to the Partners in Compassion website²⁰ and links to some of the videos utilized were also posted. The curriculum was provided to the team of Canadian nurses and doctors who went on a subsequent trip to Nepal through Partners in Compassion so that the SPH curriculum could be reviewed with the Nepalese health professionals.

Discussion

The experience in Nepal demonstrated many things about teaching SPH in a developing country. Flexibility and adapting to many different teaching environments (patient rooms, board rooms, outdoor courtyards) was imperative. For example, to accommodate the larger number of participants at the conference for hands-on learning four beds were moved into the hospital courtyard—the only place that had no patients and room to practice. Having multiple versions of the curriculum was particularly beneficial while travel teaching where the amount of time available for education was not usually specified prior to traveling to the facility. A laptop computer was very useful as several places were unable to provide a computer and projector.

An effective way to integrate knowledge into practice is to teach by example.^11,12 Observing current practices of transferring patients in addition to the available transfer and positioning equipment were all very important to the development of a curriculum that was meaningful and culturally sensitive. It was valuable to model and demonstrate the techniques in real patient situations.

Developing effective SPH programs in Nepal is limited by lack of resources, specifically a lack of appropriate equipment required for safe practice. Key pieces of equipment identified for staff and patient safety^{1–3,7,16,17,23} are simply not available in most settings in Nepal. Consequently, many of the teaching techniques and best practices being used in developed countries do not fit within the environment of a developing country.

SPH change requires both short-term and long-term support and education.^5,6,11–13 Research in developed countries has found that long-term support from all levels of the organization, including the use of administrative controls,² is needed to create a culture of change for SPH. In developed countries a timeframe of at least 2 years in order to accomplish SPH reform has been estimated.¹¹ Carta et al.⁴ found that an education program had further increases in reduction of staff reporting low back pain symptoms at 6 months into a peer led-training program when compared at 2 months. It is likely that the future of SPH in Nepal is dependent on the long-term support of staff, hospital managers, and government systems.

SPH research in developed countries has started to examine the cost effectiveness and utility of train-the-trainer and SPH coaching programs,^2,4,11 an innovation that could be tested in a developing country. Carta et al.⁴ found that a peer-led education program had reduced staff reports of low back pain symptoms. Barriers to these programs in developed countries have been identified that could also be barriers in Nepal including a lack of ongoing support, diminished continued training, poor evaluation for the trainers, and staff attrition.^5,6 A possible benefit of a peer-led program in the Nepalese system is that it may create a more long-term solution that enables the Nepalese nurses to become self-learners and self-sustained educators.

There are significant challenges to conducting research regarding SPH in developing countries. A valid analysis of the cost of unsafe practices would be difficult to complete in a developing country like Nepal due to a lack of workers' compensation and occupational health and safety organizations. As family members carry out a large proportion of patient handling in developing countries, it would also be important to include an analysis of injury levels due to unsafe practices of family members. In addition, the cost of secondary patient conditions related to poor handling and positioning would also have to be considered with acknowledgement of cultural differences in reporting pain and injuries.

Much research needs to be completed regarding SPH in developing countries, and there is limited value in comparing research findings from developed countries' as the culture, support, and resources vastly differ. Future research should examine the effectiveness, utility, and long-term change in caregiver practices for curriculums that are implemented for teaching SPH in developing countries. The prevalence of low back and shoulder pain in palliative care nurses and family caregivers of Nepalese palliative care patients should be measured before and after SPH education. It would also be important to analyze the pain, injuries, and development of secondary conditions from immobility, positioning, and assisted transfers in the experience of patients both before and after the implementation of a SPH program.

Conclusion

This project provides a description of a multidisciplinary approach to teaching SPH in a developing country. The project in Nepal revealed many areas of inquiry and insight regarding SPH education. A lack of agreement for best practices exists in both developed and developing countries and unexamined techniques are being taught.²

The effectiveness of SPH education for developing countries needs to be demonstrated through further research. Utilizing media to promote SPH education as demonstrated on the Partners in Compassion website²⁰ is a potentially effective educational strategy.^5,16 Identifying best practices for developing countries, considering unique cultural norms and limited availability of equipment, must be a priority to enhance the health and quality of life for caregivers and patients. In developing countries, where the resources of patients, families, facilities, and organizations are so limited, international development efforts, including SPH education, need to demonstrate their effectiveness so that limited resources can be directed to areas and efforts that provide the most utility and best outcomes.

Footnotes

Acknowledgments

The authors would like to thank the following: the administrators, doctors, nurses, families, and patients at Bhaktapur Cancer Hospital, Hospice Nepal, Shechen Hospice, Thankot Hospice, and Om Hospital; Diena Abdurahman (physiotherapist); Jennifer Wade (kinesiologist); Isabel Flood (registered nurse); Barb Buck (occupational therapist); Vancouver Island Health Authority; Nanaimo Community Hospice; and the International Network for Cancer Treatment and Research (INCTR) for their support of Partners in Compassion and SPH education development. Also, thank you to Susan Burgoyne (BSN, MSN) for assistance in editing this manuscript.

Portions of travel funding provided through International Network for Cancer Treatment and Research (INCTR), Partners in Compassion, and Nanaimo Hospice Community.

Author Disclosure Statement

No competing financial interests exist.

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