Musculo-skeletal injury – Are Universities doing enough to protect students?
Article Outline
- Introduction
- Student experiences of moving and handling in practice
- The rhetoric and reality of patient handling
- Protecting students from injury
- Preparing students for practice
- Conclusion
- References
- Copyright
Introduction
Internationally, the nursing profession exhibits high rates of musculo-skeletal injury, such as lower back, neck and shoulder pain (Nelson et al., 2003, Smedley et al., 2003, Hignett, 1996). Despite there being a wide range of factors which might pre-dispose nurses to injury such as age, fitness, workload intensity, staffing ratios and availability of equipment, manual patient handling activities are viewed as a key causative factor.
In the UK, European legislation and national health organisational policy discourages the use of manual approaches to handling patients due to the risk of injury to both staff and patients (HSE, 1998). The 1992 Manual Handling Operations Regulations emphasise the importance of risk assessment (HSE, 1992) and guidance from the Royal College of Nursing encourages practitioners to use handling aids to avoid manually lifting patients (Smith, 2005). Whilst on paper, advice to ‘avoid lifting’ places the practitioners safety at the forefront, a raft of research demonstrates that controversial patient handling practices continue and that practitioners do not, or cannot, always implement recommended guidelines.
Within this context, student nurses are at risk of sustaining musculo-skeletal injury early on in their nursing career (Cornish and Jones, 2007, Kneafsey and Haigh, 2007). This editorial identifies some ethical and practical issues associated with the teaching and learning of moving and handling in pre-registration nursing programmes.
Student experiences of moving and handling in practice
As a group, student nurses exhibit additional risk factors which may pre-dispose them to musculo-skeletal injury whilst undertaking clinical activities. With a minimum age of not less than 17
years for entry into pre-registration nursing programmes (Nursing and Midwifery Council, 2005), some students are not fully physically developed at the point of enrolment and may lack the muscular conditioning needed for a physically demanding job (Kier and Macdonell, 2004). Equally, students who are older at the point of enrolment may have had previous injuries making them more prone to future problems. Some students entering nurse education may also be overweight and because issues like these are not generally identified by occupational health screening as obstacles to enrolment, the students’ welfare cannot be protected.
Moving patients’ safely as well as therapeutically is a skilled activity which is initially taught in the UK in the university setting. In accordance with legal and professional requirements (Royal College of Nursing, 2000, Health and Safety Executive Manual Handling, 2004), introductory education in patient handling is provided prior to the students first clinical placement and then annually, with the expectation that further in-depth instruction and assessment will be provided during the practice placement. However, a growing body of research suggests that students’ learning experiences in relation to patient handling are less than ideal.
Early research indicated that students often knowingly conformed to dangerous patient handling practices to maintain good relations with the clinical team (Green, 1996, Kane and Parahoo, 1994). More recent research confirms that recommended practice is not always modelled in clinical areas and students continue to feel pressurised to participate in controversial practices (Cornish and Jones, 2007) Kneafsey and Haigh’s (2007) survey of 432 student nurses found that 26% (n=110) said they had begun to develop musculo-skeletal plain since becoming a student nurse with 48 citing a specific incident whilst on placement as the cause. Research by Smallwood (2006) identified that some students placed themselves in positions of risk by prioritizing patients’ well-being over their own personal safety. Other studies conclude that students have insufficient time to practise taught patient handling techniques and lack clinical supervision and teaching about patient handling (Jootun and MacInnes, 2005, Cornish and Jones, 2007, Kneafsey and Haigh, 2007). A lack of suitable patient handling equipment and the failure of practitioners’ to use equipment appropriately may also limit students’ abilities to implement taught principles (Swain et al., 2003, Smallwood, 2006).
The rhetoric and reality of patient handling
For nurses, there is often a mismatch between the rhetoric and reality in relation to patient handling. For example, in accordance with current perspectives, students are advised that manually lifting patients and using certain controversial techniques such as the ‘drag lift’ should be avoided. However, this can be difficult for students to achieve in areas where these behaviours may be routine. Furthermore, once students have been shown recommended practice, they are traditionally told that, should they injure themselves whilst using unsafe techniques; they may not be supported in a court of law.
Moving and handling in clinical practice often presents complex situations that are not easily resolved by simple application of techniques learned in a skills laboratory. The resulting dilemmas can be difficult for qualified and experienced practitioners to address and, not surprisingly, present a confusing picture for students. For example, following the introduction of the Human Rights Act (1998), revised interpretation of statutory frameworks by courts of law emphasise the importance of patients’ or clients’ needs and preferences as well as the risks to handlers (Mandelstam, 2003). Consequently, a process of balanced decision making, based on a comprehensive risk assessment, is required to justify moving and handling actions and behaviours. Controversially, Griffith and Stevens (2004) anticipates that moving and handling people manually will therefore become more frequent and the incidence of injuries in health care may rise. This perspective presents challenges for both practitioners and educationalists.
Lecturers with responsibility for this component of pre-registration curricula face an ethical dilemma. Is it right to place the burden of responsibility for ensuring good practice on students’ shoulders given the relative imbalance of power between students and employed staff? It can be difficult to educate and advise with confidence when protective strategies for students in placement are variable, lacking or unknown. However, there is an ethical requirement for universities to become more involved in establishing safe systems of work for students in the workplace.
Protecting students from injury
The UK Health and Safety Commission (HSC, 1993) defined the concept of safety culture as ‘the product of individual and group values, attitudes, competencies, and patterns of behaviour that determine the commitment to, and the style of proficiency of, an organisation’s health and safety programmes’. Since the United Kingdom Nursing and Midwifery Council requires that 50% of learning for its pre-registration programmes takes place in practice (NMC, 2006), protecting students from injury would not only necessitate universities embracing this ethos but also extending and coordinating this commitment to practice areas. It may appear that some universities adopt an ambivalent stance towards practice placement safety and skills education as a whole. Arguably, this is exacerbated by an educational paradigm which promotes adult learning and autonomy. This does not sit easily with the notion of protecting students from workplace pressures. Universities also lack power over the practices that occur in Health organisations making it difficult to safeguard students from poor practice and injury.
One starting point may be greater collaboration between educational and practice-based occupational health services to monitor and support student progression and fitness to practice. It would appear essential that Universities are notified of adverse moving and handling incidences in clinical practice involving student nurses. This would allow Universities to support students with ongoing health problems, offer health promotion or enable students to undertake modified duties whilst on placement if needed.
Unfortunately, although exposure to hazards in health care is well recognized (Health and Safety Executive, 2007) evidence suggests considerable under reporting of clinical incidents and ‘near misses’ (deCastro, 2003, Bird, 2005). A range of reasons for this exist but fear of blame and reprisal, difficulty in reporting or lack of time, and lack of clarity about the benefits of reporting feature significantly (Bird, 2005, Waring, 2005). In addition, individuals are more likely to report witnessed incidents associated with immediate outcomes and actions (for example, patient falls) rather than near misses or events which occur over time (Evans et al., 2006).
A culture that fails to emphasise the importance of safety will inevitably impact on students’ reporting behaviour. It is important that students understand the purpose and benefits of incident reporting, the types of events and situations that require reporting and their professional responsibilities in this area. Establishing a clear, non-punitive process for reporting incidents or concerns of malpractice involving Universities as well as placement areas could facilitate learning and problem solving.
Another approach could be to audit the safety of practice placement areas to at least assess the sufficiency of handling aids available. Whether this is undertaken as part of the regular educational audit currently required by the UK Nursing and Midwifery Council (NMC, 2006) is worthy of consideration. However, universities may not feel in a position to challenge service providers because of the dependency on Trusts to offer student training placements. Fear that placements will be offered preferentially to other educational providers if difficult questions are asked is a significant barrier to educationalists being involved in this process. Without clear policies on how to promote student welfare in the workplace, lecturers and students are likely to feel disempowered and personally compromised by the tension between best practice and conforming to the norms of clinical settings.
Preparing students for practice
In order to develop moving and handling skills, students need to be active participants in patient care yet the practice environment is not always well suited to explaining moving and handling techniques when patients immediate needs must be met. Students’ role models may lack the time to explain their activities or may not always demonstrate the safest and most effective methods of patient handling. At the same time, training in a university skills laboratory arguably fails to represent the complex challenges of real life practice. The dichotomy between students’ experiences in workplace settings and taught practice can leave students feeling that University practical training is irrelevant and futile.
Collaborative working is a vital approach to promoting consistency between clinical and educational services. Linking with members of practice staff may also be helpful in prioritising the tasks, techniques and equipment to be taught in the university. However, attempts to achieve continuity are more difficult where provision of student placement areas involves several trusts and, consequently, different policies, procedures and moving and handling advisors. Some teaching and learning strategies to prepare students for real life practice and the associated tensions are listed in Table 1.
Table 1. Teaching and learning strategies to prepare students for moving and handling in practice.
•Explore opinions and attitudes towards experiences of moving and handling •Use students’ reflections and concerns as a basis for meaningful training •Encourage students to translate moving and handling principles to the context of their placement workplace •Distinguish between safest practice (which may not be the ideal that is taught) and that which involves unnecessary risk •Promote problem-solving approaches to assist in dealing with unfamiliar tasks •Develop assertive and interpersonal skills to deal with the challenges and tensions of real life settings •Emphasise effective decision-making (based on risk assessment) as well as practical skills •Consider wider care-related issues that may reduce the need for manual handling •Implement interprofessional education in patient handling because at times, a range of disciplines may contribute to decisions about patients handling needs |
Conclusion
The division between university and practice-based learning in pre-registration education can result in discrepancies in teaching and practice that are difficult for students to understand or address. The nature of the practice environment poses limitations to teaching and supervision relating to patient handling. This increases the risk of students sustaining or exacerbating musculo-skeletal problems but also undermines students’ confidence in their performance and in University teaching.
Partnership between University and placement providers is essential to minimise risks of injury. The challenges of developing consistent policies and strategies between Universities and Trusts are considerable. However, to ignore this issue raises ethical questions. Educating students about patient handling methods and techniques without acknowledging and preparing them for the difficulties and dilemmas of real life practice could be regarded as negligent. A coordinated approach with regard to occupational health involvement, incident and malpractice reporting, audit procedures and continuity of teaching and learning will go some way to addressing problems related to this area of practice.
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PII: S0260-6917(09)00200-7
doi:10.1016/j.nedt.2009.10.010
© 2009 Elsevier Ltd. All rights reserved.
