Story:When I first started teaching manual handling I was sceptical around the techniques. Brought up with the other unspeakable techniques I had some convincing. I did however understand the concepts behind safe moving and handling.One morning in the car park of the hospital I worked in I witnessed a woman on crutches fall to the ground. Fortunately more embarrassed than injured. My first instinct was to rush over and help pull her up from the ground. There was no bed or chair readily available like there is in training.Then I had to remind myself that I was the manual handling coordinator and this would not be a good look if spotted!As I stood there “internalising a real complex situation in my head” I watched on as her companion also resisted the need to haul to woman up. In fact he remained quite calm. He spoke to her and verbally prompted the woman onto her hands & knees, which she managed. I thought to myself this is what I teach in my sessions. I went to their aid to assist at one side the woman to her feet. Very little effort required – she had done all the work. It was a text book execution of this technique.
Whitireia Community Polytechnic is a tertiary institution in the lower North Island of New Zealand and caters for a large Māori and Pacific Nation population. Whitireia is situated in a community where biculturalism and multiculturalism are integral to the daily lived experienced and therefore to the activities of the tertiary institution which is placed within it (Southwick, 1994).
“Using simulation to place moving and handling in context based environment in an undergraduate programme”What does this mean?Getting manual handling training and practice right at the undergraduate level is an essential piece of the puzzle when working towards the multi-factorial approach. The opportunities here are qualifying practiced practitioners who will have the confidence and competance to promote best practice.This presentation is from a nursing perspective though the concepts are transferable.
Manual Handling injuries is costing countries and nurses their careers1. 1981 the first Guide to the handling of Patients, by the National Back Association was published2. 2003 – the Royal College of Nursing reported around 80,000 nurses sustained back injury due to lifting patients (the guide to The handling of people, 5th Ed)3. Also in 2003 ACC launched the NZ Patient handling guidelines to assist the reduction of manual and patient handling injuries. The most common serious types of injuries in the health workforce. (2012 NZ moving & handling guidelines)4. 2007-2009 there was an investigation of serious injuries in the Residential Care Sector (NZ). It noted that serious injuries with greater than 60 days off work where most frequently caused by lifting patients. Return to work after 60 days was low. ACC data showed that a 28% increase in injury claims in the five year period between (2004-2008) – the cost $6 million per annum compared with the Hospital sector of an increase of 11% with a cost of $8 million per annum (NZ M&HG, section 2 p.17) 5. 2009 – International research found that the multi-factorial approach most beneficial in reducing high rates of musculoskeletal injuries among healthcare workers (NZ M&HG preface)6. 2009-10 ACC received 4,800 new workplace claims for back injuries at a cost of $126.4 million, of this 301 were from the health sector at a cost of $6.5 million (NZ M&HG, section 2 p.17)
Constraints within the traditional training model•Sheep dip learning – everyone gets taught the same – no deviation•Group rotation – only staff open to new ways engage usually due to own experience, own injury and a few with common sense•Groups for training too big, Mixed groups/disciplines. Pro – learning from each other, some disciplines have new tricks to teach others. Con’s – Over opinionated participant’s and can dominateLevett-Jones & Lathlean, 2009 noted that traditionally nursing students were socialised to obedience, respect for authority and loyalty to the team.
McAllister, (p.171) discusses the “embedded cultural tensions” in nursing. The tensions for nursing students between the “desire to belong and the need to avoid getting in the way”. She states that students “often relayed experience’s where their ideas or needs where either pushed aside or embraced” leaving them to feel either “welcomed & safe, or unwelcomed, afraid and frustrated.”She gives an example of students at times in clinical practice being asked to deal with client problems or issues that they are not familiar with not having the chance to observe the way of care first.The expectations of the student to behave like a nurse though criticised if they have modelled their practice incorrectly or unscientifically. McAllister observes the culture of care being transmitted through ritual. Rituals require repetition and are not just thought or intention, but action . Rituals are passed on from nurse to nurse. “without repetition, a useful practice (i.e manual handling) that could be shared may simply fade away”From McAllister's work she has developed extending the thank-you ritual technique (p.174) by way of giving clinical areas constructive feedbackHer Trigger activity which is a tool. The students watch /or participate in a situation then critique situation rather than clinical debriefing as this was found to draw the most painful stories that left the deepest impression.The students were also taught concept of conflict transformation• How they could have responded• How they might do it in future• Giving constructive feedbackAn example of a student not wanting to “rock the boat” was given by Levett-Jones & Lathlean where a student (in the UK) was being taught the out of date & banned manoeuvres for manual handling and not wanting to say anything – they didn’t want people to hate them.
Whitireia is currently in the process of integrating Dr Christine Tanners Clinical Judgement Model into their curriculumTanner, 2006 states that “clinical judgement is viewed as an essential skill for virtually every health professional” and sees ‘Clinical judgement is a problem-solving activity’ (p.204)One of the five conclusions Tanner drew after reviewing nearly 200 students was that ‘clinical judgements are more influenced by what nurses bring to the situation than the situation at hand’ Her model advocates not only the building of skills and knowledge but the importance of repetitiveness, of doing the same or similar activity over & over to ensure true understanding and ability to carry out an activity safely and appropriately.With noticing students familiar with patterns are better equipped to use clinical judgement in the initial assessment phaseAble to identify patterns they can interpret and respond intuitively and tacitly in the clinical situationReflection is described by Tanner as both in-action and on-action. The ability to reassess during the intervention and clinical learning from the situation. What they did well , what could they do better or differently in a similar situation?
What is simulation?To learn a skill in isolation does not reflect the true reality that health care workers find themselves in. Context is the only true way to engage in deep learning.Tanner encourages this within her clinical judgement model with repetitive learning and building of skill development.
Simulation gives a controlled environment where Students can make mistakesStudents in year one are taught the theory & practical for manual handling. They get to see, demonstrate and use the equipment. They then get to do group work where they go around workstations completing peer assessments on each other with various manual handling techniques. These techniques are then integrated into future scenarios in labs adding complexities to simple activities.
What happens when people don’t practice even basic skills
Teaching undergraduate nurses safe manual handling practice is the easy bit. Teaching them how to manage in a clinical environment where best-practice is not practiced is the challenge.There are many complexities to this challenge including:Students wanting to fit in “belong” to the area they are practicing“Students conform to clinical practices, irrespective of whether they are best-practice” (Levett-Jones & Lathlean, 2009)Rituals and culture of the clinical environmentFeeling supported, safe and able to practice what they have practiced & learned in the lab settingWith Tanners clinical judgement model and lab simulation students are given the opportunity to learn, use and practice skills taught in a variety of simulated settings building confidence and competence before reaching the clinical areas, creating their own learned rituals to which they can pass onto fellow nurses
Using simulation to place moving and handling in context based environment in an undergraduate programme
Using simulation to place moving andhandling in context basedenvironment in an undergraduateprogramme Angela Stevenson Clinical Coordinator Phil Hawes Clinical Lab Manager MANZ - March 2012
Whitireia main campus (Porirua)[20 minutes from centre of Wellington, NZ]
CONCEPT‘Using simulation to place moving and handling in context based environment in an undergraduate programme’
TRADITIONALWhat do we know?• 1981 – 1st Guide to the handling of Patients, by the National Back Association• 2003 – 80,000 nurses in the UK• 2003 – ACC launched NZ Patient Handling Guidelines• 2007-2009 Residential Care Sector , serious injury investigation• 2009 – Multi-factorial approach• 2009-2010 – 4,800 new workplace back injuries, ACC claims $126.4 million
CONSTRAINTSConstraints within the traditional training model• Sheep dip learning• Group rotation• Large training groups• Mixed groups/disciplines• Nursing students were socialised to obedience
“Embedded Cultural Tensions”• Desire to belong• Avoid getting in the way• Welcomed & safe• Unwelcomed, afraid & frustrated• Rituals of nursing(McAllister, 2008)
SIMULATION• Activities that mimic the reality of a clinical environment and are designed to demonstrate procedures, decision making and critical thinking” (Jeffries, 2005, p.97).• Studies have shown that simulation can play a role in reducing errors and mistakes in many professions including nursing (Olejniczack , 2010).
BENEFITS• Allows learners to perfect techniques• Allows learners to make mistakes• Creates a reflective environment• Encourages and develops problem solving(Issenberg , 2003)
Video clip available on YouTube athttp://www.youtube.com/watch?v=yO7sMFi1W2E
Summary• Students want to fit in• Student will conform• Ritual & Culture of environment• Students need support, feel safe & able to practice
FINAL THOUGHT“Educational practices must helpstudents engage with patients and acton a responsible vision for excellentcare of those patients and with a deepconcern for the patients’ and families’well-being”(Tanner, 2006)
REFERENCESACC Patient Handling Guildlines (2012).Jeffries, P. (2005). A framework for designing,implementing and evaluating simulations used as teaching strategies in nursing.Nursing Education Perspectives. 26 (2), 25- 30.Issenberg, S . P. (2003). Adoption and Integration of Simulation – based learning Technologies into the curriculum of a UK Undergraduate Education Programme. Medical Education 37(1),42-49.Levett-Jones, T & Lathlean, J. (2009). ‘Don’t rock the boat’: Nursing students’ experiences of conformity and compliance.’ Nurse Education Today, 29, 342-349.McAllister, M. (2008) Thank-you cards: Reclaimimg a nursing student ritual and releasing its transformative potential. Nurse Education in Practice. 8, 170-176.Olejniczak, E. & Brown, J. (2010). Simulation as an orientation strategy for new graduate nurses: An integrative review of the evidence. Simulation in Healthcare. 5 (1), 52- 57.Tanner, C. (2006). “Thinking Like a Nurse: A Research-Based Model of Clinical Judgment in Nursing" Journal of Nursing Education. June Vol.45, No.6 204-211.The Guide to Handling of People, 5th Ed (UK)
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