P36: Bit about meToday I will be highlighting how we are Handling physiotherapy education in New Zealand- more specifically, at Auckland’s AUT University.As you can see, I have worn a few different hats- firstly practicing for 7 years as a registered nurse, then as a physiotherapist and lecturer for nearly 10. In that time I was also one of the inaugural “Champions” of the Liten Up programme at Waitemata DHB, which is now nicely in the hands of the MHANZs chair,Anne McMahon.So, unlike Sonny Bill here who is making the journey to Aus, this presentation aims to take you through the journey we have taken at AUT in developing our Moving and Handling curriculum.Before me: Angela Stevenson (P8) RN Whitireia Community Polytechnic- Simulation for undergrads (safety, challenge implementing guidelines, realistic, problem solve)After me: Jillian Adams (P24) WA, Aus RN- Predicting and preventing manual handling injuries (reduction of injury…)
The Bachelor of Health Science (physiotherapy) is a four year degree with between 130 (2011) and 160 (2010)first year studentsThe first year starts with six months of common core papers- papers which are foundational for a number of Health Science programmes- including nursing, midwifery, Occupational Science and Therapy (occupational therapy), podiatry and sports and recreation. Then in the second semester, the students are streamed into their programmes, with “Therapeutic Touch” being one of the first year papers for the Physiotherapy Students. This paper aims to ….Apply a variety of basic massage and moving and handling techniques;Discuss physiological and psychological effects, socio-cultural, ethical and legal considerations, and concepts of professional practice.While in the making for the last 6 years, AUT University has gone about a change of curriculum in the physiotherapy programme, which has been rolled out over the last 2 years. Have we got it right… …definitely not.. … yet
In order to look at better look at where we are now in the curriculum, and direction for the future, I will reflect on how Moving and Handling was presented in the past in the undergraduate programme.Overall, the students received 8 hours of direct moving and handling tuition.In the first year, there was a one hour lecture that briefly introduced some statistics, legislation, biomechanics, and introduction to the Liten up approach.This was then taken to the practical labs which comprised of 3 two hour sessions in year one, and 1 one hour session in year two- going over identified techniques in the Patient Handling GuidelinesThis was followed by their clinical placements in years three and four. Here is where they first applied the techniques in the clinical settingAnd it was very much learning about techniques- for a given manoeuvre, a step by step list of instructions was provided, in some instances straight from the Patient Handling Guidelines, demonstrated, then worked on.
The more traditional approach to teaching, one that the majority of us here would have been taught with, is the Didactic approach.This is one where the Active participant is the Teacher. The teacher taught TO the student who passively absorbing the content. While there is no denying that there can be some active learning taking place, the environment of the Didactic approach can be restrictiveThis approach is one where the content is presented as hard facts; where we give them a step by step approach to one right way- and thereby, unintentionally, implying that all other ways are wrong; and therefore perceived as unsafe.The teacher is seen as being the expert- what they say is Gospel, and not questionable or negotiableHere, the secret to success is to memorise all the content that is given; and to mimic the manoeuvre exactly the same way as the teacher-just as an Australian parrot would do…
A lot of the information that was passed on in the lecture and labs resulted in rote learning. By providing the students with step by step instructions, we were telling the students that there was no other way- that this was the only right way. This was the same with learning legislation and biomechanics- they could spout out the principles from the lecture word for word, though could not demonstrate or describe how it might play out in a given clinical situation.Although the etiquette of professional practice was taught, and reinforced in the labs, when it came to the examination and clinical placement, the students went through the steps of introduction, explanation, and informed consent as a task- as if they were ticking it off the list- there was no sense of genuineness to their approachMost importantly, they could not problem solve:For example, as a result of delivering a large amount of ‘techniques’ in a short space of time, if a manoeuvre was demonstrated in the practice lab transferring a patient left to right, the student could not relate that knowledge into how to move the patient in the opposite direction right to left. Same with chair to bed; or using a ‘different’ hoist in clinical placement compared to the one that was brought into the first year labs (thanks to ArjoHuntleigh)Despite effort to provide the student with adequate techniques for clinical placement, the feedback from the clinical educators was that they did not retain basic principles, and students were unable to transfer knowledge to a given clinical scenario- be it transferring in a different direction; a different age of patient; or a different piece of equipment
Time: Lecture: 1.5hrLab: 3 x 2 hrsHave ‘clinical observation’ in year 1Have ‘clinical observation’ in year 2/ and ‘patient labs’ where people with different conditions come into AUT for the students to assess and apply their handling skillsThis reflects what was in the draft version of the new Patient Handling Guidelines… “…what is learnt during training [should be] applied immediately [so] that the process of making these practices routine begins while the learning is still fresh.”More time in ‘patient labs’ in year 3 (for instance, 8 hours of hands-on assessment and treatment of healthy older adult; children and neurological patientsHave “passport to practice’ lab early in year four- check M & H skills prior to a year (1200 hours) of clinical placementShift to Scenario/ problem solving basedNotice a huge change in the lab book over the past few yearsNotice that the lab book has gotten thinner-less step by step instructions for each manoeuvre, more space for the student to enter in their own take on the technique (i.e. Experimental)
Focus on handling skills (foundations of hands-on therapy)Learn foundations/ principlesLego-ethical emphasis (Niki)BiomechanicsRisk AssessmentEquipment (sliding sheet); principles (hoist, transfer board)LectureDefinition of Moving and Handling (NZ OSH Code of Practice for Manual Handling (2001)Statistics (related to the studentsLegal responsibilities (Health and Safety in Employment Act (1992; 2002); OSH Code of Practice for Manual Handling (2001); ACC Act (2001); Hospital Policies & Procedures; Code of Rights (1994; 1998; 2004); Privacy Act (1993)Liten up approach- Risk assessmentBiomechanical Principles- BoS; COM; COG; Lever armAnatomy (brief)- joints; bones, discsPositioningLabsFocus on their handling skills- remember, most of these students would not have laid hands on a patientProfessional approach- Risk Assessment (LITE)Introduction, Explain, Informed Consent; Safety; EquipmentPrepare environmentBiomechanicsReady, steady moveRe-evaluatePatient comfortUse of equipment- hospital beds; wheelchairs; sliding sheets; transfer boards; principles of use of hoistsWhen looking back at past lecture and lab handbooks, there is a notable reduction in the amount of text provided, instead, more space for the student to write in their own instruction…
We have a pool of around 10 different scenarios that we use for the assessment of the students in their first year. They incorporate techniques as outlined by the ACC Patient Handling guidelines; professional practice; the value of therapeutic positioning; use of an assist; and verbal prompts.Scenario 1: Provides some detail as to their ability, which they need to consider. Remember, that at this point in their undergraduate programme, they would have only observed 2 hours of clinical practice. They are then instructed what the task at hand is- in this scenario it would be a lateral roll to the left.They are finally asked to position the patient using bed pillow, wedges, and towels as appropriate. All the while, the student’s ability to be professional in their approach- for instance- introduction, explanation, informed consent and feedback to/ from the patient in regards to comfort, are assessed.Scenario 2: Incorporates a consideration of a special populationand the patient’s ability (grade 2 strength); this assesses the student’s ability to provide instructions (and also demonstrates their level of understanding). This also looks at the student’s ability to consider the other helper in this scenario- to take the lead; and to consider the helpers Individual attributesScenario 3:This scenario tests the student to rely mainly on their ability to verbally prompt a patient through a manoeuvre, thereby enabling independence. It tests the student’s ability to demonstrate how they would help a patient using procedural or skill- based learning (in essence- how we are teaching the student)All of these scenarios are modified, so that we can observe the student’s ability to progress the patient, or to see how they would adapt to differing levels of ability. The student’s ability to apply biomechanical principles such as COM, lever arm and base of support, are observed, or demonstrated verbally
So we have adapted with a shift in our teaching approach- from Didactic, to a namely “Experimental approach.Where the Didactic approach saw a more passive student, the Experimental enables the student to me more active in their learning, with the teacher facilitating or directing where to look for the answers- rather than providing them in hard text for them to regurgitate. They may be provided some foundational principles, then asked to problem solve a question incorporated into a clinical scenario. It shift from the Didactic approach where there is only one right way. While there remains to be safe ways of performing a task, there may be many approaches that could be considered right as long as those principles are maintained. Can draw on their personal experience, i.e. moving up a bedWhere the Didactic approach saw the teacher as being the expert; the Experimental approach shifts the power to the student- they take ownership of their learning, while questioning with the teacher leads to, what the literature calls, a mutual contemplation of a given scenarioHere, success is with the student being provided a clinical scenario, where they are able to explore and experience, to some degree, a real situation, and be able to problem solve a multitude of possibilities and progressionsSo there is an emphasis on their procedural learning (learning by doing) rather than declarativelyProcedural- in that works best for motor/ task learning, rather than the factsBy experimenting in the labs, they were more adapt to being able to modify and progress their handling
Adapted from Shumway Cook & Woollacott (2011) & Perry (1991)IndividualConsiders the perception and cognition of the patient, as well as the action and abilities of both the patient and the therapist (i.e. the Load and the Individual)TaskThe what, how, and when of the task at handEnvironmentWhile Environment in this model can refer to external factors that influence movement such as the type of surface we walk on; or the lighting in a room; the size, shape and weight of a person is considered in the Regulatory factors, as OUR movement needs to conform, or is regulated by these considerations of the patient.Non-regulatory factors may affect the performance of the moving and handling task, though does not need to conform- such as background noise, and the presence of a busy environment.Understanding the features within the environment that both regulate and affect the performance of movement tasks (such as in moving and handling patients) is essential in the planning of intervention
Year One remains the ‘best fit’ for principles of Moving and Handling- especially the latter. The first year paper is their first taster of what it might be like to be a health professional. If we do not get the handling right here, we spend the next 3 years undoing bad habits (i.e. lack of consent, unprofessional behaviour, poor handling)With an emphasis on developing community awareness, the content of the phsyiotherapy programme has shifted. Anatomy and kinesiology is not presented up front in year one- instead is integrated throughout the year. For instance, when a case scenario involves someone with a stroke, the student learns the appropriate neuroanatomy, signs and symptoms of a stroke, and appropriate assessment and treatment. When the case has osteoarthritis of the knee, the student learns about differential diagnosis, the anatomy of the knee and again appropriate assessment and treatment.The timing of when anatomy and pathophysiology teaching remains contentious within the lecturing team, and is currently under discussionThere seems to be a fine balance of teaching the students principles of use of equipment, and hands on use of different types. There remains to be some mixed feedback from clinical supervisors as to how much the student knows in regards to equipment, and their ability to readily apply principles that they have picked up.With an experimental approach to the students learning, it is sometimes difficult to ensure that all 160 students have received the same level of knowledge- that is, prior to their examination where consistency is moderated. That being said, in 2011, 7/129 students (or 5%) failed their M&H component and were required to resit this part of the exam.
Sometimes you go through a process with more questions than answers, though this might also be seen as food for thought…Year one- patient labs at Northbridge (morning assistance- getting patients in rest-home and hospital ready for day)Functional transfersIn and out of carInclusion of M&H ‘inanimate objects’ All Wales NHS Manual Handling Training Passport & Information Scheme (2003)Videos though dilemma with what YouTubeReflection of updated Patient Handling Guidelines (2011)
I leave you with this…I appreciate that this is probably still a contentious dilemma, and one that is not just isolated to physiotherapy practice. While many of the techniques that are provided in the guidelines are aimed at supporting an independent patient, or one who is dependent and therefore needing mechanical assistance, a lot of our contact with patients geared to rehabilitation, which fits more in the middle of these two extremes.Here- we may be wanting to provide the patient with some Experience of taking and shifting their own weight, to excite neurophins and thereby the neural synapses by overloading their senses- by challenging for instance their balance thereby stimulating their proprioception, somatosensation, or muscle length tension.When they are in a dependent state, neurosynaptically, they do not adapt- a principle of neuroplasticity that is therefore untapped unless we have challenge it. Neutrophins (such as brain derived growth factor) promote neurons forming in response to stimulation- mainly of external environmental cues.It is difficult to give permission to the student to provide this challenge to the rehabilitation patient, if they are to adhere only to the techniques that are laid out in the guidelines.Therefore, it can be seen, that with the new physiotherapy curriculum providing a foundation to Moving and Handling, and a problem solving approach to clinical scenarios, the hope, is that the student is better equipped in their evolving practice.Time, will tell…Thank-you.
How are we HANDLING physiotherapy education: Where’s New Zealand MOVING ?
How are we HANDLINGphysiotherapy education: Where’s New Zealand MOVING (P36) Todd Stretton Lecturer, AUT University, Auckland MPhil(Hons), PGDipRehab, BHSc (Physiotherapy, Nursing) Image: http://thehightackle.files.wordpress.com/2011/09/sonny-bill-williams.jpg
BHSc (Physiotherapy)• Four year programme – 130- 160 first year students – First Semester: common core papers – Second Semester: “Therapeutic Touch” paper • Moving and Handling Component• Recent (2 years) changes in the curriculum• Have we got it right…. – Definitely not… …yet
The Past• Timeframe: Year One Year Two Year Three Year Four• Learnt “techniques”
How have we HANDLED teaching before?Didactic• Active Teacher Passive Student• Answers & Facts• Right and wrong• Teacher centred – knower and expert• Memorise + Mimic = Success
Teaching didactically lead to some ‘problems’…• Rote learning- techniques, legislation and biomechanics• Lost emphasis of Professionalism• Could not problem solve – Left right… …???? Right left – Chair to bed … …??? Bed to chair – Equipment• Did not retain practical foundations at time of clinical placement
The Present• Timeframe: Year One Year Two Year Three Year Four• Clinical scenario’s
Lecture Practical Labs• Definition • Focus on their handling skills• Statistics (brief) • Use of equipment- hospital• Legal Responsibilities beds; wheelchairs, sliding• LITEN up approach/ Risk sheets; transfer boards; hoists assessment (principles)• Biomechanical principles• (Brief) anatomy• Therapeutic Positioning
How have we MOVED our teaching?Didactic Experimental• Active Teacher Passive Student • Facilitating Teacher Active Student• Answers & Facts • Questions mutual ‘contemplation’• Right and wrong • Scenario based & Problem Solving• Teacher centred • Student centred – knower and expert – Problem solver/ critical thinker• Memorise + Mimic = Success • Experience + Problem Solve = Success
Still, not without its problems…• Year One remains the ‘best fit’ for principles of Moving and Handling• Anatomical and pathophysiological knowledge very limited• Equipment- principles vs. hands on use of e.g. hoists• Still need to assess the students consistently • When not given the directive, the weaker students struggle…
The Future• Labs with “Patients”• Functional transfers (e.g. in and out of car)• Inclusion of M&H ‘inanimate objects’• Videos• Reflection of updated Guidelines (2011)
An On-going Issue…?• Independent• REHABILITATION• Dependent
Thank-youTodd StrettonLecturer, AUT University, Aucklandtodd.email@example.com