Slide 1

Hoisted beyond safety

Beyond Safety

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Providing best care and outcomes for Bariatric Patients

Aideen Gallagher Risk ManagedThe BIG Issue

9 May 2016

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OUTLINE

MANUAL HANDLING

DISCUSSION

RISK MANAGEMENT

EXPLORATION OF EQUIPMENT

Today I have been asked to talk about manual -handling for the client of size. Between now and 3:30 we are going to do the following things.

I am going to introduce the idea of manual handling and hear about the challenges you are having in your role in terms of manual handling. I will then present about what the literature is saying the problems are and see how much your experience reflects that.We are going to look at starting to address these manual handling challenges and it is embedded in risk assessment. I am going to get you to challenge the way you engage with risk assessment to see how we can take a fresh opportunistic look at it as opposed to fear based.Finally we are going to try and apply risk assessment to some manual handling challenges by engaging with some of the equipment we have to offer here at the workshop.We will conclude with a de-brief and sum up after which there will be free exploration time

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MANUALHANDLING

Kay, Glass and Evans published a really interesting article in 2014 on manual handling providing an outline of how we are doing in manual handling as well as a bit about the history of manual handling. They describe how manual-handling interventions that we know today gleaned from the petrochemical industry. Interventions of outlining exactly what people had to do and telling they to just do it was successful in that industry therefore this philosophy was transferred to the manual handling space. Unlike the petrochemical industry, one person completes a task with an inanimate object. What is different in people handling is that people have to engage with each other to complete any manual-handling task.

Person Environment Occupation (PEO) Model (Law et al, 1996)

This diagram illustrates the PEO model of occupational performance, which we all learn in university. It basically says that the person interacts with the environment, through the tasks they do and the way they do it. This diagram assumes that one person interacts with the environment through the task however in manual handling there is always at least two people and in bariatric care, sometimes more. What was a simple diagram now gets complicated and we feel somewhat surprised when manual handling is complicated.

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Person Environment Occupation (PEO) Model (Law et al, 1996)

If you look at this diagram it essentially includes everything you have to consider when addressing a manual handling issue and some of these factors are indeed more important than others. The tasks are manual handling transfers, the performance becomes how we do them and the aim in the middle is a safe and efficient transfer. This concept of efficiency is a key point I want to come back to later

I had the opportunity to attend the Australian Association for the Manual Handling of people (AAMHP) this time last year. It was a three-day conference with some prominent speakers on manual handling. In the presentations I attended, it took until the last day before I heard anyone talk about manual handling being a social activity. What I mean by this is that it involves a communication as well as a physical activity and when I talk about communication, I mean a negotiation. The social side of manual handling is something I will touch on later too

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What are the greatest manual handling challenges are you coming across in your practice with clients of size?

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MANUALHANDLINGTASKS

TRANSFERRINGREPOSITIONINGMOVING EQUIPMENT (Retasas & Piniahana, 2000)LIFTING LIMBS (Nelson et al, 2006; Muir & Archer, 2008)MOBILISING CLIENT (Rose et al, 2006)SHOWERING (Muir & Archer, 2008)

TRANSFERSSHOWERING - pannus, unpredictable flesh movement (Hignett et al, 2007)MOVING equipment and client (Crowley and Leggett, 2010)LIFTING LIMBS - 30% weight total body weight (Nelson et al., 2006)2.4 increase in staff to assist patient to MOBILSE Rose et al (2007)

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TONS(Nelson et al, 2004; Tuhoy-Main, 1997) 8 hour shift Nurse was lift cumulative weight of

TIMESKILLWORKERSEQUIPMENT

INCREASED(Muir and Archer, 2008)

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35% BARIATRIC TRAINING (Hignett et al 2007)58% 50% STAFFING CHANGE (Scott, Pokorny & Rose, 2010)67%POLICY (Hignett et al 2007)EQUIPMENT (Hignett et al 2007) (Scott, Pokorny & Rose, 2010)THE ENVIRONMENTSOCIAL and ECONOMIC SYSTEMSNO

POLICY - directions

Hignett et al 2007 found that only 42% of surveyed institutions had a policy for bariatric clients, although 28% reported that their organisations did not adhere to this policy very well. 35% of health trusts no extra manual handling training in regard to bariatric clients (Hignett et al 2007)Scott study - Over 50% of the nurses surveyed reported that no special staffing accommodations were made by the home care agency to take care of morbidly obese patients 50% casesOnly 33% of the home health nurses reported having the equipment they needed to care for these patients. This is slightly more than a previous study noted where only 22.5% had the resources they needed (Carr, 2008)

WHEN DID YOU LAST USE A HOIST? 42% LAST 30 DAYS; 40% NOT IN OVER A YEAR (Whipple, 2008)NO LIFT AMBULANCE (Crowley and Legette, 2008)EXIT PLANCOMMUNITY IN HOSPITAL OUT

THE ENVIRONMENTSOCIAL and ECONOMIC SYSTEMS

Whipple is 2008 surveyed nurses on a ward with a prominent bariatric clientelle and asked when did you last use a hoist?

6% calls to the ambulance services are for just a lift alone.

In terms of Ambulance workers it is interesting that a care giver can say no to lifting a client whereas there is an expectations that two workers in a mobile van arriving to a situation after a brief over the phone is. This really highlights also the cultural environment that can come into play when assisting the person of size.

WEIGHT SHAPE SIZE (Crowley and Leggett, 2010)RECTANGULAR SQUARE (Crowley and Leggett, 2010)UNEQUAL WEIGHT (Hignett & Griffiths, 2009)STATIC DYNAMIC double SWL (Crowley and Leggett, 2010)INDUSTRIAL APPEARANCE (Crowley and Leggett, 2010)THE ENVIRONMENTEQUIPMENT

I had a client recently who was living in department of housing with cerebral palsy and 120kg. She was mobilizing but was unsteady of her feet. This meant that when she transferred from sitting to standing she would drop onto the chair as she lost her balance slightly in the inegress. This is what this static/dynamic point alludes to.

Sandi Lightfoot Collins suggests that a doubling of the SWL is needed for a client in this category who falls into a piece of equipment. This means with a client of 120kg, a chair of 240kg plus is needed to accommodate her weight. Sandi shared stories with us at the last conferences of fractures toilet bowls because of this very issue.

In my case, there was a dissonce as the client needed a chair of weight capacity 240kg but not massively wide as she was not an overly large lady but this was the only option that was available which made her outgrown her house sooner while she was weight bearing and she would probably fit it again when she was non weight bearing.

CLIENT

SHAPE Rush (2002)WEIGHT ? DISTRIBUTION (Hignett & Griffiths, 2009)REDUCED MOBILITY (Fife et al., 2007)ENDURANCE (Hignett & Griffiths, 2009)UNCOOPERATIVE (Nelson et al, 2006;Kneasfey, 2000)FEARDIGNITY (Crowley and Leggett, 2010)

THE PERSON

BODY SHAPE DRAW ON THE BOARD

We know about the physical stuff

This is the part I am really interested in.. The social bit and this and the next slide

I think there is an attitude in manual handling that people should just be able to do it

But of course we know that is not going to happen

UNCONSCIOUS STIGMATISATION (Berger, 2007)OVERWHELMING (Coates, 2010)EQUIPMENT ACCEPTANCE (Crowley and Legette, 2008)CLIENT COOPERATION (Crowley and Legette, 2008)BARIATRIC JOURNEY (ASCC, 2009)MORE WORKERS = SAFER? (Kayess et al, 2013)THE ENVIRONMENTSOCIAL

The interaction between both is frustrating people

OHS Card

Because of this we are using the what we call OHS card where we say for OHS reasons you must do x,y,z. This is legitimate but I think it so threatening and dismoralising for a person where there are so many other options if we upskill ourselves.

I think if we learn the art of negotiation we can listen, understand, appreciate, give control to the person and work together to solve this problem. Once you play the OHS card, you might damage a therapeutic relationship forever.17

SOC!ALPhysicalHandlingManual

Yes manual handling is physical but it is also social.

To get over these barriers We need to listenWe need to understandWe need to enable the person grieveWe need to give control

RISKASSESSMENT

Risk management is the process we use to solve manual handling problems.

I feel this is the key to starting to be able to cope with the tsumani that is upon us in terms of the manual handling of the bariatric person.

In preparation for this talk, I talked to a number of key people around the world who have knowledge in bariatric care and many of them say they are still learning. There is so much unknown and we need a framework for making good effective and efficient decisions. We are still learning and we are continuing to learn and risk assessment is the process through which we are going to find the answers. I am going to challenge the way you engage with is today to determine if we can use it to enable as opposed to hinder function.

RISK MANAGEMENT

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RISK

ASSESSMENTSeverityLikelihood

In terms of risk assessment, we assess it in terms of the likelihood of something happening and the severity of the event if it occurs. What is it? Risk? What is risk?

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RISK

DangerLossInjuryHarmTherapeutic Risk TakingBenefitsOpportunityDignity of Risk

When we look at the word risk in the manual handling sector, it has many negative connotations (word cloud on slide) and you would kinda wonder who would ever want to work in it. When we look beyond that, for example in mental health, we get many positive words associated with risk we talk about opportunity.

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SAFETYEfficiency

Because we only ever engage with risk assessment when danger is present, our aim in manual handling has been to make things safe. We rarely look at making things efficient.23

FEAR

A second consequence is that if we look at risk assessment when danger is present we engage with it out of dear. There is still a real fear culture with the workplace health and safety arena of which manual handling is a cousin. We are really fearful about being wrong and can find ourselves hanging onto rule. We will talk about rules later.

Talk about Ken Robinson, children with give it a go24

HARMFULNon therapeuticOPPORTUNITYTherapeuticPositive Negative

RISK TAKING

Getting back to risk being seen in a slightly broader light, risk can therefore describes risk assessment on a continuum where you get positives/enablers and negatives/barriers. Almost like a thermometer, when the temperature gets hot, you turn it down.

I think this is important because in mental health, risk assessment in engaged with all the time to test whether there are risks with a certain action with a client. If there are unwanted outcomes we control for them and enhance the positives. The key is that risk assessment is engaged with, not just when danger is present, but to test out options and check if they are merited.

Enabling Occupation

Has anyone heard of this gentleman? His name is Warren MacDonald. He is Australian and he is a double amputee, speaks across the world about resilience and positive risk taking. A picture of this gentleman is probably the reason why we went into OT, it encapsulates Enabling Occupation. I preparation for this presentation, I contacted Warren and asked him about his goal to mountain climb when he first had his accident. He describes a scenario when he was learning to fall. (read quote from Warren).

Disconnect

I had a classic situation where I was supposed to learn how to fall in my prosthetics, because it's going to happen, right?And while we have a mat set up in front of me and everything, next thing I've got two health professionals, having this conversation, one each side of me, discussing whether we should do this or not.I'm watching this conversation back and forth, and decided; we're dong it; and just fell forward.They were kind of freaked, but my thing was; "what, are we going to wait and let me fall outside while I'm on my own

This scenario explains how we as therapists use risk assessment and the barriers we place on ourselves in risk assessment. If we dont do it, we will be safe, but if we do it, look at how much we will achieve.

abcdHOISTONOFFONOFFCHAIRONOFFOFFON

When positioning in the chair from a hoist what brakes go on where?

Lets apply this to manual handling. This is a very simple but common debate in manual handling breaks on the hoist when positioning in a chair. Which is it? - Slide with question poll?

Whilst I am interested in your answer, I am more interested in the process you used to get there.

RULESHandlingManual

Manual handling is full of rules and I would ask where these rules came from? Who says? And is this credible? Based on research?I would ask you to think about who the rules are for? A care worker doing a job wants the petro-chemical answer, a set or directions and guidelines that say just do this. But what about therapists? Should we always be a sheep and follow these rules? Where should our professional development as clinicians come from?

Picture at beach sometimes rules make us forget what the actual aim is

Three minute rule

Child - Sometimes the consequence of putting a rule into practice has so many negative outcomes

Many of us learn about these rules from senior colleages but as ODonnell so eloquently put it

making the same mistakes with increasing confidence over an impressive number of years.experience means. ODonnell,1997

A lot of the time it is through social interactions between staff where the senior member of staff dictates what to say. However ODonnell in (2007) out it really nicely when he saidTo many people "experience" means "making the same mistakes with increasing confidence over an impressive number of years".

We have this Chinese whispers scenario where the rule is re-written slightly and can actually miss the point.

Or we just become a sheep, completely de-skilled following the leader when the leader may not actually be on the right path

How many of you have worked this out? By not working it out, are we creating barriers when there are already enough?

Creativity is allowing yourself to make mistakes. Art is knowing which ones to keep

Scott Adams

Csikszentmihalyi (1997) discusses creativity in terms of effective problem solving, where divergent ideas are used to find workable solutions. He links creativity with risk, identifying that to be creative is to take a risk. In a clinical setting, where risk is regularly reduced to its harmful elements, a reluctance to engage with risk limits the extent to which a clinician can be creative in.(18)

RISK MANAGEMENT

CREATIVE RISK MANAGEMENT

I am therefore suggesting a new way of looking at risk assessment and suggesting a two-step process to risk assessment. Involving divergent thinking first to be creative in problem solving and using risk assessment to test out your ideas for safety.

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Positive implicationsWhat problem might be solved if this action was put in place? Are there any further opportunities or actions that could be made easier because of this? What is the likelihood of there being positive consequences?

Negative implicationsIs there a likelihood of any injury if this action was put in place? How might that occur? Whats the severity of the injury if an incident did take place?How can I enhance the positive/helpful actions and control the negative/unhelpful actions?OPTIONS?

RISK

CONTROL HIERARCHYEliminateSubstitutionIsolationEngineering ControlsAdministration Controls

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RESIDUAL RISK

We need to recognise there will be residual risk because of all the factors in the PEO model that feed into manual handling 38

Lets start looking beyond safety to efficiency, lets start to use RA to test options, lets start using risk assessment to find opportunities.

NBANEXTBESTALTERNATIVE

A really important aspect of risk assessment is comparing. In the decision making literature a lot is written about comparing with the next best alternative. Sometimes this can be a really good way in manual handling to see where is the best option to go with. What is the alternative and check to see which is the lesser of the two evils40

PRACTICAL PROBLEM SOLVING

1. BED MOBILITY STATIONLying to sitting sitting to lying transferSit to stand and stand to sit from the bed2. HOIST STATIONTest scenario of brakes on wheelchair and hoistCompare standard yoke with four pronged hoist3. FLOOR TRANSFERS IN SITTING STATIONHow many of your manual handling problems could this solve and how?4. LYING TRANSFERS HOVER MATHow many of your manual handling problems could this solve and how?

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abcdHOISTONOFFONOFFCHAIRONOFFOFFON

When positioning in the chair from a hoist what brakes go on where?

Lets apply this to manual handling. This is a very simple but common debate in manual handling breaks on the hoist when positioning in a chair. Which is it? - Slide with question poll?

Whilst I am interested in your answer, I am more interested in the process you used to get there.

BARIATRICRESOURCES

ALGORITHMS(Dr Audrey Nelson)BEDCHAIRS(Baptiste, 2007)FRICTIONREDUCTIONDEVICES (Nelson & Baptiste, 2007).HOISTS (McGinley &Burke, 2008)MOVEMENTPATTERNS (Christine Colavitti, QLD)HOVERMATS (Coates, 2012)RESOURCES

Lifting cushions!

Muir, M. & Archer, G. (2008). Safe Patient Handling of the Bariatric Patient: Sharing of Experiences and Practical Tips When Using Bariatric Algorithms. Bariatric Nursing and Surgical Patient Care, 3(2), 147-158A practical resources examining common manual handling scenarios in bariatric care and possible solutions.

Coates, E. (2012). A path following approach to bariatric patient transfers. Safety Institute of Australia Conference Sydney, 2012 https://www.sia.org.au/downloads/Conferences/NSW/2012-sydney-safety-conference/speaker-presentations/elissa-coates.pdfAn excellent presentation by Elissa Coates providing practical tips and algorithms for problem solving patient care as well as equipment options

Kay, K., Glass, N. & Evans, A. (2012). Its not about the hoist: A narrative literature review of manual handling in healthcare. Journal of Research in Nursing 19(3), 226-245An engaging and informative discussion on the origins of manual handling interventions and their effectiveness

USEFUL RESOURCES

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Safe Bariatric Patient Handling Toolkit- http://www.visn8.va.gov/patientsafetycenter/safePtHandling/BariatricsToolkit.pdfA publication by Dr Audrey Nelson outlining how to manage the Bariatric client Safe Bariatric Patient Handling Toolkit. BARIATRIC NURSING AND SURGICAL PATIENT CARE Volume 2, Number 1, 2007, 17-45A practical resource to problem solve the management of the bariatric client

Cowley SP, Leggett S. (2010). Manual handling risks associated with the care, treatment and transportation of bariatric patients and clients in Australia. International Journal of Nursing Practice 2010; 16: 262267

Bariatric care in Australia

USEFUL RESOURCES

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MEDIAWarren MacDonald - photography reproduced with permissionThree minute rule - Lars Ploughmann - Creative commons licence - FlickrBeach scene - Ricardo Liberato - Creative commons licence FlickrSheep - Amanda Slater Creative commons licence - FlickrStairs - Creative commons licence - FlickrLaw M, Cooper B, Strong S, Stewart D, Rigby P, Letts L (1996) The Person-Environment-Occupation Model: a transactive approach to occupational performance. Canadian Journal of Occupational Therapy, 63(1), 9-23. - Diagram reproduced with permission from CAOTREFERENCES/RESOURCES

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Nelson A, Matz M, Chen F, Siddharthan K, Lloyd J, Fragala F. Development and evaluation of a multifaceted ergonomics program to pre- vent injuries associated with patient handling tasks. Int J Nurs Studies 2006;43:717733. Kneafsey R. The effect of occupational social- ization on nurses patient handling practices. J Clin Nurs 2000;9:585593. Nelson A, Matz M, Chen F, Siddharthan K, Lloyd J, Fragala F. (2006) Development and evaluation of a multifaceted ergonomics program to pre- vent injuries associated with patient handling tasks. Int J Nurs Studies 2006;43:717733. Nelson A, Baptiste A. Evidence-based practices for safe patient handling and movement. Online J Issues Nurs 2004;9:4. Available at www.nurs- ingworld.org/ojin/topic25/tpc25_3.htm. Accessed 8 January 2007.McGinley, L.D. & Burke, J. (2008). Best Practices for Safe Handling of the Morbidly Obese Patient. BARIATRIC NURSING AND SURGICAL PATIENT CARE Volume 3, Number 4, 2008, 255-260.Gallagher, A. (2014). Risk Assessment: An enabler or barrier? British Journal of Occupational Therapy. Coates, E. (2012). A path following approach to bariatric patient transfers. Safety Institute of Australia Conference Sydney, 2012 https://www.sia.org.au/downloads/Conferences/NSW/2012-sydney-safety-conference/speaker-presentations/elissa-coates.pdf

Rose M. Nurse staffing requirements for care of morbidly obese patients in the acute care setting. Bariatr Nurs Surg Patient Care 2006;1:115120.

Kay, K., Glass, N. & Evans, A. (2012). Its not about the hoist: A narrative literature review of manual handling in healthcare. Journal of Research in Nursing 19(3), 226-245

Rose M. Nurse staffing requirements for care of morbidly obese patients in the acute care setting. Bariatr Nurs Surg Patient Care 2006;1:115120.

Berger E. Emergency departments shoulder challenges of providing care, preserving dignity for the super obese. Annals of Emergency Medicine 2007; 50: 443445.

Card by Fredrik Rubensson is licenced under CC by 2.0 addition of caption OHS card

REFERENCES/RESOURCES

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Muir, M., & Archer-Heese, G. (2009). Essentials of a bariatric patient handling program. Online Journal of Issues in Nursing, 14(1), 1.

Muir, M., & Gerlach, S. (2003). Reducing the risks in bariatric patient handling. The Canadian Nurse, 99(8), 2933

Muir, M., & Heese, G. A. (2008). Safe patient handling of the bariatric patient: Sharing of experiences and practical tips when using bariatric algorithms. Bariatric Nursing and Surgical Patient Care, 3(2), 147158.

Cowley SP, Leggett S. (2010). Manual handling risks associated with the care, treatment and transportation of bariatric patients and clients in Australia. International Journal of Nursing Practice 2010; 16: 262267

Hignett, S., Griffiths, P., Chipchase, S., Tetley, A. (2007). Risk Assessment and Process Planning for Bariatric Patient Handling Pathways. www.hse.gov.uk/research/rrhtm/rr573.htm

Scott, E. S., Pokorny, M. E., Rose, M. A., & Watkins, F. (2010). Safe handoffs for the morbidly obese. Bariatric Nursing and Surgical Patient Care, 5(1), 7174.

Whipple, K. L. (2008). Maximizing healthcare provider safety while rehabilitating the bariatric patient. Bariatric Nursing and Surgical Patient Care, 3(1), 4145.

Australian Safety and Compensation Council (2009). MANUAL HANDLING RISKS ASSOCIATED WITH THE CARE, TREATMENT AND TRANSPORTATION OF BARIATRIC (SEVERELY OBESE) PATIENTS IN AUSTRALIA. Commonwealth of Australia

Retsas, A., & Pinikahana, J. (2000). Manual handling activities and injuries among nurses: an Australian hospital study. Journal of Advanced Nursing, 31(4), 875-883.

Rush, A. (2002). Overview of Bariatric Management. Disabled Living Foundation.: http://www.dlf.org.uk/news/archive/anitarush.html

Fife C, Benavides S, Otto G. Morbid obesity and lymphedema management. Lymph Link Newsletter 2007; 19: 13.

Nelson A, Baptiste A. Evidence-based practices for safe patient handling and movement. Online J Issues Nurs 2004;9:4.

McGinley, L.D. & Burke, J. (2008). Best Practices for Safe Handling of the Morbidly Obese Patient. BARIATRIC NURSING AND SURGICAL PATIENT CARE Volume 3, Number 4, 2008, 255-260.

Kayess, R., Valentine, K., Thompson, D., Meltzer, A. & Fisher, K. (2013) Research on the need for two care workers in a community setting. For Ageing, Disability and Home Care, Department of Family and Community Services NSW Social Policy Research Centre

https://www.flickr.com/photos/comedynose/6939206771/in/photolist-bzcfq4-aoFsF9-dXwQCS-dXrafv-kKPAVS-graNZj-bg8dcr-gjvLc5-944LFa-a9PZ48-dyLUhH-mKiLC8-qjWAQB-r5kDHb-fLFr49-9FBMBF-61baGa-bjmKX4-e82EJ8-boJ5jC-aCWhkm-9pF9Sh-pPyvhx-dCVoK9-dXwPKu-iynY4g-8SJq5F-ax2vp6-4JzJrH-fQdypu-qo7GcF-graRRD-dXra7n-bi4E42-o2KeAL-e2fPV2-dySp2L-dySp5w-dXwPjC-aeq5Ud-nW2bqy-o4MAmr-pxahVf-ovQMkL-voF4oG-dXram8-dXr8HV-4EYnCE-o4Faad-o4MCjz

Nelson A, Baptiste AS. Evidence based practices for safe patient handling and movement. Online Journal of Issues in Nursing 2004;9(3).Tuohy-Main K. Why manual handling should be eliminated for residents and career safety. Geriaction 1997;15:10-14.

REFERENCES/RESOURCES

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CONTACT

aideengallagher@risk.managed.com.auwww.riskmanaged.com.au