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Validation of an instrument for patient handling assessment
ARTICLE IN PRESS
Applied Ergonomics 35 (2004) 321–328
Validation of an instrument for patient handling assessment Cremilde A. T. Radovanovic, Neusa M. C. Alexandre* ! Department of Nursing, School of Medical Sciences, State University of Campinas (UNICAMP), Cidade Universitaria 2Zeferino Vaz’’, CEP 13083.970, Campinas, Sao * Paulo, Brazil Received 5 September 2002; received in revised form 1 August 2003; accepted 22 March 2004
Abstract Nursing personnel are at high risk from work-related musculoskeletal disorders, especially back symptoms. Handling patients has been established as one of the factors playing an important role in the etiology of occupational low back pain. The aim of this study was to develop an instrument for patient handling assessment and to determine its validity and reliability. Instrument validity was established based on content and construct validity. Reliability was estimated through homogeneity, stability (test–retest) and equivalence (interrater) tests. Reliability estimated by internal consistency reached a Cronbach’s Alpha coefficient of 0.81. Pearson’s correlation coefficient for test–retest reliability was r ¼ 0:92: There was an excellent agreement between observers, according to the k values (Kappa=0.92). Interobserver (interrater) reliability was assessed by Pearson’s correlation coefficient, reaching an r value of 0.84. The agreement between both observers was also fairly good (Kappa=0.84). The results of the current study show that the instrument seems to be reliable and valid for patient handling assessment. r 2004 Elsevier Ltd. All rights reserved. Keywords: Ergonomics; Handling patients; Low back problems; Nursing
1. Introduction Nursing personnel are at high risk of developing work-related musculoskeletal disorders, especially back symptoms (Fuortes et al., 1994; Larese and Fiorito, 1994; Niedhammer et al., 1994; Leigthon and Reilly, 1995; French et al., 1997; Ando et al., 2000). A great part of back injuries in health care professionals is related to inadequate ergonomic conditions of furniture, workplace and equipment used in daily activities. Handling patients has been regarded as one of the main factors playing an important role in the etiology of . occupational back pain (Lagerstrom et al., 1998; Engkvist et al., 2000; Goldman et al., 2000; Retsas and Pinikahana, 2000). The procedures that involve moving and lifting patients are considered the most painful for the nursing team. Special training sessions with an ergonomic approach should be complemented by an evaluation of the patient, environment and equipment. Studies have been carried out to evaluate handling procedures. Some researchers have prepared checklists to verify how the *Corresponding author. E-mail address: [email protected] (N.M.C. Alexandre). 0003-6870/$ - see front matter r 2004 Elsevier Ltd. All rights reserved. doi:10.1016/j.apergo.2004.03.007
nursing team performs patient handling tasks following a training program (Alavosius and Sulzer-Azaroff, 1985; Feldstein et al., 1990). Other studies have evaluated patient handling techniques using video recording and a rating scale (Troup and Rauhala, 1987; Videman et al., 1989). Kjellberg et al. (2000) validated an observational instrument for description and assessment of work techniques used by nursing personnel in patient transfer tasks. Another author conducted a laboratory study to evaluate the amount of physical exertion required of nurses in manual lifting techniques (Winkelmolen et al., 1994). However, instruments for a systematic evaluation of patient needs as well as special risks have not been discussed in the literature. The aim of this study was to develop an instrument for patient handling assessment, and to determine the validity and reliability of this instrument.
2. Material and methods 2.1. Study design The research was conducted at a University Hospital, in two admission units: the Intensive Care Unit (ICU)
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and the Cardiology Clinic Unit. These wards were selected for treating patients with different characteristics concerning their moving and transference needs, according to the methodological orientation of construct validity. The research presents three phases: development of the instrument, validity evaluation and reliability evaluation. In order to facilitate validity and reliability evaluation, at times data on the same group of patients were used, without losing sight of methodological accuracy. Twenty-eight of the 30 nurses working at the Intensive Care Unit participated in the research. 2.2. Development of the instrument The instrument was developed with the objective of evaluating patient handling. Reports in the literature demonstrate that handling skills should be complemented by the establishment of safe work practices, in an ergonomic structure supported by the use of assistive devices (National Back Pain Association, 1997; Owen, 2000). To reach this target one of the first steps involves a systematic evaluation of risks and patient needs. The selection of instrument items was based on publications on the subject (Bell, 1987; Pheasant, 1987; McAtamney and Corlett, 1992; Caboor et al., 2000). The instrument is in a form to be filled out by a health care professional, possibly as part of the patient record. It includes eight topics, each of them with three alternatives. These topics are: weight, height, level of consciousness, mobility in bed, transfers from bed/stretcher or bed/chair and vice versa, walking, catheters and equipment, in addition to patient environment. Each one of these topics is described below: Weight: 1=equivalent to weight up to 50 kg, 2= indicates weight between 51 and 69 kg, 3=indicates weight equal to or higher than 70 kg. Weight range standardization was based on study carried out by Dehlin and Jaderberg (1982), who developed a method of assessing perceived exertion during patient lifts. Height: 1=equivalent to height up to 1.50 m, 2= indicates height between 1.51 and 1.79 m, 3=indicates height equal to or higher than 1.80 m. Height classification was based on data presented by Bevilacqua et al. (1991) found acceptable by the panel of six experts during the content validity assessment. Level of consciousness: 1=alertness, 2=confusion/ lethargy, 3=unconsciousness/motor agitation. Mobility in bed: 1=independent, 2=able to move with assistance, 3=dependent. Transfer from bed/stretcher or bed/chair and vice versa: 1=independent, 2=able to transfer with assistance, 3=dependent. Walking: 1=independent, 2=able to walk with assistance, 3=dependent. Catheters and equipment used by the patient: 1=up to one accessory: the patient does not have any or else has
only one accessory or piece of equipment connected, 2=two to four accessories: the patient has from 2–4 accessories or pieces of equipment connected, 3=more than five accessories: the patient has five or more accessories pieces of equipment connected. The following items are considered accessories: urinary catheters, nasogastric/enteral tubes, drains, intravenous feeding tubes, peripheral and central catheters, and colostomy bags. The pieces of equipment that should be monitored are: monitors, respirators, infusion pumps, oximeters, hemodialyzer, intra-aortic balloon pump, pace-maker generator, hypo/hyperthermal mattresses, trans-skeletal and cutaneous traction. Special risks: 1=good: when the environment does not pose risks to the nursing team during the process of moving and transferring the patient. It has adequate physical space and floors, an adjustable height bed, bed and wheelchair with wheel locks, 2=risk potential: one of the following risk factors is present: restricted physical space, irregular floors or bed with nonadjustable height, bed and wheelchair without wheel locks, making it difficult to move or transfer the patient, 3=risk: when the environment presents two or more risk factors, such as irregular floors, restricted physical space or bed with non-adjustable height, bed and wheelchair without wheel locks. 2.3. Score determination By means of observation and interviews the health care professional is able to determine the values for each topic on a scale from 1 to 3. As the instrument comprises eight topics, the minimum score possible will be eight points and the maximum score 24 points, with 17 points of variation between the minimum and maximum scores. The categories for low, medium and high risk were determined after discussion with the six experts during content validity evaluation. By dividing the 17 points into (newly) equal parts, as follows: 08–12=‘‘Low risk’’ when moving and transferring the patient; no assistance necessary, supervision is required. 13–18=‘‘Medium risk’’ when moving and transferring the patient; patient may need assistance, some type of handling aid or support technique. 19–24=‘‘High risk’’ when moving and transferring the patient; seek assistance, select hoist or other appropriate handling aid. 2.4. Instrument validity evaluation 2.4.1. Content validity The instrument was submitted for evaluation to a panel of six experts, who were asked to analyze and present suggestions about the objectivity, appropriateness
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and clarity of the instrument. The six judges were nurses, three of whom were university professors and three who worked at a University Hospital. After this phase, a pilot study was carried out with 25 randomly selected patients. 2.4.2. Construct validity A method that consists of the analysis of two known groups (sometimes called contrasted-groups approach— LoBiondo-Wood and Haber, 1998) was used, through which contrasting answers to the instrument items are expected. In order to test construct validity a comparison was made between two groups of patients who presented different characteristics regarding their moving and transportation requirements. The instrument was administered to 40 patients selected at random; 20 patients from the Cardiology Clinic unit and 20 patients from the Intensive Care Unit (ICU). ICU patients require care with a high-degree of complexity and dependence, being adult patients from different postoperative, transplantation and trauma units. Cardiology is a unit planned for the care of adult patients with clinical pathologies, who need an intermediate degree of care. 2.5. Instrument reliability evaluation Reliability was estimated through stability (test– retest), equivalence (inter-rater) and homogeneity assessment. 2.5.1. Stability (test–retest) In order to analyze stability, agreement between the same nurses was verified regarding filling out the instrument at the beginning and end of the shift. Test– retest was evaluated with 28 nurses at the ICU, in two phases and under similar conditions. The nurses were informed of the research objectives and invited to participate voluntarily. 2.5.2. Equivalence interobserver (inter-rater) Equivalence was verified by agreement between two observers or raters when simultaneously filling out the instrument. The instrument was administered to 28 ICU patients at the same time by two independent observers– one of the researchers and one of the ICU nurses. Instrument administration occurred at the beginning of the shift and there was no communication between the observers while the forms were being filled out. 2.5.3. Homogeneity In order to evaluate internal consistency, the data already collected during the inter-rater and construct validity tests were used. Thus, consistency was analyzed by examining the instrument applied to 48 patients.
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Among these patients, 28 were from the ICU and the other 20 from the Cardiology Clinic. 2.6. Ethical considerations The project obtained approval from the University’s Ethics Committee on Research, under No. 370/2000. The participation of nurses was voluntary and all signed a letter of consent. 2.7. Statistical analyses The data obtained were transferred to a spreadsheet and tabulated with the aid of Microsoft EXCELs computer software and analyzed under the orientation of the Statistics Service of the University’s Research Committee. In order to evaluate construct validity the difference between ICU and Cardiology instrument scores was analyzed using the Chi-square and MannWhitney tests. The internal consistency of the instrument was evaluated by means of Cronbach’s Alpha coefficient, and Kappa’s coefficient and Pearson’s correlation coefficient were used to evaluate stability and equivalence.
3. Results 3.1. Instrument validity analysis 3.1.1. Content validity After evaluation of the instrument by six experts and completion of the pilot study, when the format, scale topics, values of each topic and classification of risk evaluation were carried out, the instrument was rewritten and the final version obtained (see the Appendix A for a copy). 3.1.2. Construct validity First of all a descriptive analysis of the data may be observed in Table 1. A non-parametric Mann-Whitney test was also used to compare the score obtained by administering the instrument to 20 patients admitted to the ICU and 20 patients admitted to the Cardiology Unit. Analyzing the results in Table 1 it is noticed that the analyzed units, ICU and Cardiology, provided Table 1 Descriptive statistics on the scores obtained by administering the instrument at the ICU and cardiology wards Unit
N
Average
S.D.
Minimum
Median
Maximum
ICU CARDIO
20 20
18.9000 12.8000
2.8078 1.8524
13 11
19.5 12.0
23 18
Mann-Whitney Test: p value=0.0001.
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Table 2 Instrument result distribution regarding risk classification (low, medium and high risk) in ICU and cardiology wards
Table 3 Evaluation of agreement by the same nurses, at separate moments, at the ICU, regarding score classification
Risk
Beginning of shift
ICU N
Cardiology %
N
%
Low risk (08–12) Medium risk (13–18) High risk (19–24)
0 9 11
0 45 55
12 8 0
60 40 0
Total
20
100
20
100
Chi-square=0.0001.
End of shift Low risk
Medium risk
High risk
Total
N
N
N
N
Low risk Medium risk High risk
0 0 0
0 9 0
0 1 18
0 10 18
Total
0
9
19
28
Kappa=0.92.
3.2. Instrument reliability analysis 3.2.1. Stability In order to analyze stability, agreement between the same nurses was verified regarding filling out the instrument at the beginning and end of a shift. The Kappa coefficient (k) was calculated. Values higher than 0.75 represent very good agreement and Kappa values below 0.40 indicate weak agreement. Kappa values between 0.40 and 0.75 represent intermediate agreement (Fleiss, 1981). The results of this phase of the study may be observed in Table 3. The data showed excellent agreement between the nurses at the beginning and the end of shift, as the Kappa value was 0.92. It was noted that among the 28 participants who administered the instrument, 27 (96.4%) agreed to fill out the instrument at the beginning and at the end of shift and only one (3.6%) changed their answer at the end of shift. To confirm that there is correlation among nurse scores, Pearson’s
24 22
End of shift
statistically different results. As the ICU median score was 19.5, a value significantly higher than that observed at the Cardiology Unit, it seems that the ICU poses a higher risk in the tasks involved when handling patients. In order to confirm the results obtained, the difference in risk evaluation scores was also analyzed (Table 2). The Chi-square test was used to check if there were differences, with a significant association when p-value was p0.05. The data showed that there is a statistically significant difference between scores obtained in the two units studied, confirming that the instrument is able to detect risks present during patient moving and transfer procedures. At the ICU there was prevalence of the ‘‘high risk’’ (55%) and ‘‘medium risk’’ (45%) classifications, concerning evaluation of risks detected when performing these procedures. At the Cardiology Unit the opposite result was obtained. Therefore, it was demonstrated that the ‘‘low risk’’ classification prevailed (60%), followed by the ‘‘medium risk’’ (40%) classification.
20 18 16 14 12 14
16
18
20
22
24
Beginning of shift Fig. 1. Dispersion diagram of nurse scores obtained at the beginning and end of shift (r ¼ 0:92).
correlation coefficient (r) was used. The data may be seen in Fig. 1. The results indicate a positive correlation between scores obtained at the beginning and end of shift by the same nurses. Pearson’s correlation coefficient presented a value ðrÞ ¼ 0:92; considered excellent, confirming the agreement between nurses. 3.2.2. Equivalence In order to evaluate equivalence reliability the agreement between both observers, when simultaneously filling out the instrument at the beginning of shift, was verified. For analysis purposes the results of scores classified as ‘‘low’’, ‘‘medium’’ and ‘‘high’’ were used, calculating the Kappa (k) coefficient. Data are presented in Table 4. The test showed that there was good agreement between results when the instruments were administered simultaneously and to the same patient, presenting a Kappa value=0.84. It was also seen that among the 28 instruments administered by each of the observers, 26
ARTICLE IN PRESS C.A.T. Radovanovic, N.M.C. Alexandre / Applied Ergonomics 35 (2004) 321–328 Table 4 Evaluation of agreement between both observers, regarding score classification Nurse
Researcher Low risk
Medium risk
High risk
Total
n
N
N
n
Low risk Medium risk High risk
0 0 0
0 9 1
0 1 17
0 10 18
Total
0
10
18
28
Kappa = 0.84.
24
Researcher
22
20
18
16
14 14
16
18
20
22
24
Nurse Fig. 2. Dispersion diagram of nurse and researcher scores obtained at the beginning of shift (r ¼ 0:84).
participants (92.8%) agreed with the researcher when filling it out and only two participants (7.2%) disagreed with the answer on the instrument. Pearson’s correlation coefficient was used to check the existence of correlation between scores. The data may be seen in Fig. 2. Pearson’s coefficient showed a value of r ¼ 0:84; considered satisfactory and indicating there is positive correlation between the scores obtained by both observers. This test confirmed the existence of agreement between the observers. 3.2.3. Consistency In order to verify the internal consistency of the instrument items, Cronbach’s Alpha coefficient—obtained from the results of 48 instruments administered in two different hospital wards—was calculated. Estimated reliability based on internal consistency obtained a Cronbach’s Alpha total of 0.81, with coefficients varying from 0.73 to 0.87. These data showed that there is homogeneity among the instrument items.
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4. Discussion The present study validated and verified the reliability of an instrument developed to evaluate patient handling tasks, making it possible to estimate the kind of assistance required. The suggestions of the judges validating the content and the results of the pilot study made it possible to build a clearer and more objective instrument. Construct validity was evaluated using the known groups technique, which contrasts scores of groups regarded as different in relation to the studied attribute. It was demonstrated that the instrument might provide an effective evaluation of risks. It was noticed that the Intensive Care Unit patients are at a greater risk than the patients admitted to the Cardiology Unit. The instrument was able to detect the differences between wards. This was as expected, confirming the importance of an evaluation to perform tasks related to patient handling, when risks and specific patient characteristics should be taken into account. It is hoped that new research will test the instrument with different kinds of patient and health institutions. The analysis of the internal consistency evaluation showed that the instrument presents homogeneity among its items. It was not necessary to remove any item from the instrument, as the data revealed an Alpha total of 0.81, demonstrating that the instrument is reliable. Expert judgments were used for the selection of topics and weights. The instrument included eight topics that were separately analyzed. Regarding patient weight, some authors strongly recommend evaluating and planning the whole process in detail when handling obese patients, with the aid of mechanical devices whenever possible (Marras et al., 1999; Engkvist et al., 2000). In a study carried out by Alexandre and Angerami (1993), the second most frequent complaint of nurses regarding patient transportation is related to patients weight. Although the literature has not discussed the height of patients, in practice this factor may require a greater number of employees to perform tasks related to patient handling. With reference to the level of consciousness, most patients in the ICU were unconscious and highly dependent, which is considered a special problem arising in specific handling situations (National Back Pain Association, 1997). Dependent patient transfers may be one of the factors that cause work-related injuries and has been shown as a contributing factor to low back pain (Alexandre and Benatti, 1998; Engkvist et al., 1998; Owen, 2000). Experts recommend the utilization of mechanical lifting devices and auxiliary materials to minimize back compression forces and subsequent risk of back problems (Ulin et al., 1997; Marras et al., 1999; Alexandre et al., 2001).
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Concerning the topic that evaluates accessories and equipment connected to patients, a significant percentage of individuals made use of more than five accessories, which presented difficulties in transferring and moving these patients. Some authors emphasize that before starting a transfer it is important to evaluate patient conditions (Troup and Rauhala, 1987; Winkelmolen et al., 1994; Alexandre and Rogante, 2000). Several authors recommend training programs on patient transfer techniques as preventive measures to avoid back pain and injuries among nursing professionals and also to draw attention to the importance of the use of assistive devices in patient transferring and moving procedures (Zhuang et al., 1999; Marras et al., 1999; Kjellberg et al., 2000; Elford et al., 2000). The first step to begin training on adequate transfer methods is to evaluate environmental risks. Restricted physical space poses limitations to movement and is pointed out as one of the causal agents of back pain in nursing personnel (McAtamney and Corlett, 1992; McAtamney and Hignett, 1993; Botha and Bridger, 1998). McAtamney and Hignett (1993) say that risk factors should be considered in the evaluation of the workplace and equipment. Some authors discuss the importance of the use of height-adjustable beds in nursing, as this makes it easier to handle and minimizes the effort made to lift patients (Bell, 1987; Pheasant, 1987; Botha and Bridger, 1998; Caboor et al., 2000). It was considered important to evaluate all patient circumstances, such as weight, height, consciousness, dependence level (mobility, transfer and walking), accessories and equipment connected to the patient, in addition to special risks. All these topics are considered in the current instrument; other topics may be added to the instrument, according to where it will be used. The evaluation of reliability by means of test–retest stability showed that there is agreement between the scores of the same nurses who administered the instrument on two separate occasions. The data demonstrated a result of 96.4% agreement between nurse responses at the beginning and at the end of shift. Every instrument should produce identical or very similar results when administered at different times, considering the same patient. Reproducibility was evaluated first for agreement and correlation of scores measured by the same nurses at two distinct times, at the beginning and at the end of the shift. Kappa’s coefficient (p ¼ 0:92) and Pearson’s coefficient (r ¼ 0:92) results confirmed that the instrument is reproducible and reliable in a specific period of time. Equivalence reliability verified there was agreement and correlation between two different observers through the simultaneous filling out of the instrument. The evaluation of this stage was done by using
Kappa’s coefficient, which obtained a result of p ¼ 0:84; demonstrating good agreement between observers. Pearson’s coefficient, equal to r ¼ 0:84; also indicated positive correlation. By means of equivalence analysis it was verified that the instrument is easy to understand, since the results demonstrated were considered reliable. In order to conduct patient handling assessment in a health-care institution it is important to consider the specific characteristics of each unit and of its patients. The administration of the instrument developed in this research may provide a background for health care workers to make plans to provide assistance in accordance with the dependence degree and needs of each patient. The instrument may also help to follow up the evolution of the patient. Based on this planning, the health care worker will be able to define the best handling method. 4.1. Limitations of this study This instrument was tested with only two kinds of patients, according to the methodological requirements of construct validity. It is hoped that now other studies will test the instrument in other hospital locations, like orthopedic, geriatric and neurological wards. New research should be conducted extending its use to different populations. The topics that make up the instrument may also be modified in other studies, depending on the location and on the patients involved. Nonetheless, the present study will help to fill a void in this area. It is hoped that it will arouse interest on the theme and act as support for further research on the subject.
5. Conclusions A new instrument was developed to evaluate patient handling. Construct validity presented a significant difference between both units studied, demonstrating that the instrument was able to detect these differences. The internal consistency analyzed by Cronbach’s Alpha coefficient demonstrated that the instrument presents homogeneity of components. The stability test, evaluated by administration of the instrument by the same nurses at two different moments demonstrated excellent agreement, through the Kappa coefficient result. There was also positive correlation shown by the data obtained by Pearson’s coefficient. Equivalence was evaluated by simultaneous administration of the instrument by two observers and analyzed by Kappa and Pearson’s coefficients. It was demonstrated that there was satisfactory agreement between the observers.
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The results indicated that the instrument is viable and that it may contribute to a better planning of nursing assistance, together with other preventive ergonomic strategies. The instrument may help health care workers to systematically plan the level of assistance needed.
Acknowledgements The authors wish to thank Rosaly Davis for editing the manuscript. Appendix A
PATIENT HANDLING ASSESSMENT FORM Name: Ward: Admission date:
Age: Bed: Diagnosis:
Mark a value from 1 to 3 according to the evaluation of each item. Data Weight
Height
Level of consciousness
Mobility in bed
Transfer
Walking
Catheters and equipment
Special risks
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Concepts Up to 50 Kg 51– 69 Kg > 70 Kg Up to 1.50 m 1.51- 1.79 m > 1.80 m Alertness Confusion/lethargy Unconsciousness/restlessness Independent Able to move with assistance Dependent Independent Able to transfer with assistance Dependent Independent Able to walk with assistance Dependent Up to 1 2 to 4 accessories + 5 accessories Good Risk potential Risk
Points
Days in hospital
1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3
Total Record scores and the level of assistance needed: 08-12 = “Low risk”= No assistance necessary. Supervision required. 13-18 = “Medium risk” = Patient may need assistance, some kind of handling aid or selected technique. 19-24 = “High risk” = Seek assistance, selected hoist or other appropriate handling aid.
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Applied Ergonomics 35 (2004) 321–328
Validation of an instrument for patient handling assessment Cremilde A. T. Radovanovic, Neusa M. C. Alexandre* ! Department of Nursing, School of Medical Sciences, State University of Campinas (UNICAMP), Cidade Universitaria 2Zeferino Vaz’’, CEP 13083.970, Campinas, Sao * Paulo, Brazil Received 5 September 2002; received in revised form 1 August 2003; accepted 22 March 2004
Abstract Nursing personnel are at high risk from work-related musculoskeletal disorders, especially back symptoms. Handling patients has been established as one of the factors playing an important role in the etiology of occupational low back pain. The aim of this study was to develop an instrument for patient handling assessment and to determine its validity and reliability. Instrument validity was established based on content and construct validity. Reliability was estimated through homogeneity, stability (test–retest) and equivalence (interrater) tests. Reliability estimated by internal consistency reached a Cronbach’s Alpha coefficient of 0.81. Pearson’s correlation coefficient for test–retest reliability was r ¼ 0:92: There was an excellent agreement between observers, according to the k values (Kappa=0.92). Interobserver (interrater) reliability was assessed by Pearson’s correlation coefficient, reaching an r value of 0.84. The agreement between both observers was also fairly good (Kappa=0.84). The results of the current study show that the instrument seems to be reliable and valid for patient handling assessment. r 2004 Elsevier Ltd. All rights reserved. Keywords: Ergonomics; Handling patients; Low back problems; Nursing
1. Introduction Nursing personnel are at high risk of developing work-related musculoskeletal disorders, especially back symptoms (Fuortes et al., 1994; Larese and Fiorito, 1994; Niedhammer et al., 1994; Leigthon and Reilly, 1995; French et al., 1997; Ando et al., 2000). A great part of back injuries in health care professionals is related to inadequate ergonomic conditions of furniture, workplace and equipment used in daily activities. Handling patients has been regarded as one of the main factors playing an important role in the etiology of . occupational back pain (Lagerstrom et al., 1998; Engkvist et al., 2000; Goldman et al., 2000; Retsas and Pinikahana, 2000). The procedures that involve moving and lifting patients are considered the most painful for the nursing team. Special training sessions with an ergonomic approach should be complemented by an evaluation of the patient, environment and equipment. Studies have been carried out to evaluate handling procedures. Some researchers have prepared checklists to verify how the *Corresponding author. E-mail address: [email protected] (N.M.C. Alexandre). 0003-6870/$ - see front matter r 2004 Elsevier Ltd. All rights reserved. doi:10.1016/j.apergo.2004.03.007
nursing team performs patient handling tasks following a training program (Alavosius and Sulzer-Azaroff, 1985; Feldstein et al., 1990). Other studies have evaluated patient handling techniques using video recording and a rating scale (Troup and Rauhala, 1987; Videman et al., 1989). Kjellberg et al. (2000) validated an observational instrument for description and assessment of work techniques used by nursing personnel in patient transfer tasks. Another author conducted a laboratory study to evaluate the amount of physical exertion required of nurses in manual lifting techniques (Winkelmolen et al., 1994). However, instruments for a systematic evaluation of patient needs as well as special risks have not been discussed in the literature. The aim of this study was to develop an instrument for patient handling assessment, and to determine the validity and reliability of this instrument.
2. Material and methods 2.1. Study design The research was conducted at a University Hospital, in two admission units: the Intensive Care Unit (ICU)
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and the Cardiology Clinic Unit. These wards were selected for treating patients with different characteristics concerning their moving and transference needs, according to the methodological orientation of construct validity. The research presents three phases: development of the instrument, validity evaluation and reliability evaluation. In order to facilitate validity and reliability evaluation, at times data on the same group of patients were used, without losing sight of methodological accuracy. Twenty-eight of the 30 nurses working at the Intensive Care Unit participated in the research. 2.2. Development of the instrument The instrument was developed with the objective of evaluating patient handling. Reports in the literature demonstrate that handling skills should be complemented by the establishment of safe work practices, in an ergonomic structure supported by the use of assistive devices (National Back Pain Association, 1997; Owen, 2000). To reach this target one of the first steps involves a systematic evaluation of risks and patient needs. The selection of instrument items was based on publications on the subject (Bell, 1987; Pheasant, 1987; McAtamney and Corlett, 1992; Caboor et al., 2000). The instrument is in a form to be filled out by a health care professional, possibly as part of the patient record. It includes eight topics, each of them with three alternatives. These topics are: weight, height, level of consciousness, mobility in bed, transfers from bed/stretcher or bed/chair and vice versa, walking, catheters and equipment, in addition to patient environment. Each one of these topics is described below: Weight: 1=equivalent to weight up to 50 kg, 2= indicates weight between 51 and 69 kg, 3=indicates weight equal to or higher than 70 kg. Weight range standardization was based on study carried out by Dehlin and Jaderberg (1982), who developed a method of assessing perceived exertion during patient lifts. Height: 1=equivalent to height up to 1.50 m, 2= indicates height between 1.51 and 1.79 m, 3=indicates height equal to or higher than 1.80 m. Height classification was based on data presented by Bevilacqua et al. (1991) found acceptable by the panel of six experts during the content validity assessment. Level of consciousness: 1=alertness, 2=confusion/ lethargy, 3=unconsciousness/motor agitation. Mobility in bed: 1=independent, 2=able to move with assistance, 3=dependent. Transfer from bed/stretcher or bed/chair and vice versa: 1=independent, 2=able to transfer with assistance, 3=dependent. Walking: 1=independent, 2=able to walk with assistance, 3=dependent. Catheters and equipment used by the patient: 1=up to one accessory: the patient does not have any or else has
only one accessory or piece of equipment connected, 2=two to four accessories: the patient has from 2–4 accessories or pieces of equipment connected, 3=more than five accessories: the patient has five or more accessories pieces of equipment connected. The following items are considered accessories: urinary catheters, nasogastric/enteral tubes, drains, intravenous feeding tubes, peripheral and central catheters, and colostomy bags. The pieces of equipment that should be monitored are: monitors, respirators, infusion pumps, oximeters, hemodialyzer, intra-aortic balloon pump, pace-maker generator, hypo/hyperthermal mattresses, trans-skeletal and cutaneous traction. Special risks: 1=good: when the environment does not pose risks to the nursing team during the process of moving and transferring the patient. It has adequate physical space and floors, an adjustable height bed, bed and wheelchair with wheel locks, 2=risk potential: one of the following risk factors is present: restricted physical space, irregular floors or bed with nonadjustable height, bed and wheelchair without wheel locks, making it difficult to move or transfer the patient, 3=risk: when the environment presents two or more risk factors, such as irregular floors, restricted physical space or bed with non-adjustable height, bed and wheelchair without wheel locks. 2.3. Score determination By means of observation and interviews the health care professional is able to determine the values for each topic on a scale from 1 to 3. As the instrument comprises eight topics, the minimum score possible will be eight points and the maximum score 24 points, with 17 points of variation between the minimum and maximum scores. The categories for low, medium and high risk were determined after discussion with the six experts during content validity evaluation. By dividing the 17 points into (newly) equal parts, as follows: 08–12=‘‘Low risk’’ when moving and transferring the patient; no assistance necessary, supervision is required. 13–18=‘‘Medium risk’’ when moving and transferring the patient; patient may need assistance, some type of handling aid or support technique. 19–24=‘‘High risk’’ when moving and transferring the patient; seek assistance, select hoist or other appropriate handling aid. 2.4. Instrument validity evaluation 2.4.1. Content validity The instrument was submitted for evaluation to a panel of six experts, who were asked to analyze and present suggestions about the objectivity, appropriateness
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and clarity of the instrument. The six judges were nurses, three of whom were university professors and three who worked at a University Hospital. After this phase, a pilot study was carried out with 25 randomly selected patients. 2.4.2. Construct validity A method that consists of the analysis of two known groups (sometimes called contrasted-groups approach— LoBiondo-Wood and Haber, 1998) was used, through which contrasting answers to the instrument items are expected. In order to test construct validity a comparison was made between two groups of patients who presented different characteristics regarding their moving and transportation requirements. The instrument was administered to 40 patients selected at random; 20 patients from the Cardiology Clinic unit and 20 patients from the Intensive Care Unit (ICU). ICU patients require care with a high-degree of complexity and dependence, being adult patients from different postoperative, transplantation and trauma units. Cardiology is a unit planned for the care of adult patients with clinical pathologies, who need an intermediate degree of care. 2.5. Instrument reliability evaluation Reliability was estimated through stability (test– retest), equivalence (inter-rater) and homogeneity assessment. 2.5.1. Stability (test–retest) In order to analyze stability, agreement between the same nurses was verified regarding filling out the instrument at the beginning and end of the shift. Test– retest was evaluated with 28 nurses at the ICU, in two phases and under similar conditions. The nurses were informed of the research objectives and invited to participate voluntarily. 2.5.2. Equivalence interobserver (inter-rater) Equivalence was verified by agreement between two observers or raters when simultaneously filling out the instrument. The instrument was administered to 28 ICU patients at the same time by two independent observers– one of the researchers and one of the ICU nurses. Instrument administration occurred at the beginning of the shift and there was no communication between the observers while the forms were being filled out. 2.5.3. Homogeneity In order to evaluate internal consistency, the data already collected during the inter-rater and construct validity tests were used. Thus, consistency was analyzed by examining the instrument applied to 48 patients.
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Among these patients, 28 were from the ICU and the other 20 from the Cardiology Clinic. 2.6. Ethical considerations The project obtained approval from the University’s Ethics Committee on Research, under No. 370/2000. The participation of nurses was voluntary and all signed a letter of consent. 2.7. Statistical analyses The data obtained were transferred to a spreadsheet and tabulated with the aid of Microsoft EXCELs computer software and analyzed under the orientation of the Statistics Service of the University’s Research Committee. In order to evaluate construct validity the difference between ICU and Cardiology instrument scores was analyzed using the Chi-square and MannWhitney tests. The internal consistency of the instrument was evaluated by means of Cronbach’s Alpha coefficient, and Kappa’s coefficient and Pearson’s correlation coefficient were used to evaluate stability and equivalence.
3. Results 3.1. Instrument validity analysis 3.1.1. Content validity After evaluation of the instrument by six experts and completion of the pilot study, when the format, scale topics, values of each topic and classification of risk evaluation were carried out, the instrument was rewritten and the final version obtained (see the Appendix A for a copy). 3.1.2. Construct validity First of all a descriptive analysis of the data may be observed in Table 1. A non-parametric Mann-Whitney test was also used to compare the score obtained by administering the instrument to 20 patients admitted to the ICU and 20 patients admitted to the Cardiology Unit. Analyzing the results in Table 1 it is noticed that the analyzed units, ICU and Cardiology, provided Table 1 Descriptive statistics on the scores obtained by administering the instrument at the ICU and cardiology wards Unit
N
Average
S.D.
Minimum
Median
Maximum
ICU CARDIO
20 20
18.9000 12.8000
2.8078 1.8524
13 11
19.5 12.0
23 18
Mann-Whitney Test: p value=0.0001.
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Table 2 Instrument result distribution regarding risk classification (low, medium and high risk) in ICU and cardiology wards
Table 3 Evaluation of agreement by the same nurses, at separate moments, at the ICU, regarding score classification
Risk
Beginning of shift
ICU N
Cardiology %
N
%
Low risk (08–12) Medium risk (13–18) High risk (19–24)
0 9 11
0 45 55
12 8 0
60 40 0
Total
20
100
20
100
Chi-square=0.0001.
End of shift Low risk
Medium risk
High risk
Total
N
N
N
N
Low risk Medium risk High risk
0 0 0
0 9 0
0 1 18
0 10 18
Total
0
9
19
28
Kappa=0.92.
3.2. Instrument reliability analysis 3.2.1. Stability In order to analyze stability, agreement between the same nurses was verified regarding filling out the instrument at the beginning and end of a shift. The Kappa coefficient (k) was calculated. Values higher than 0.75 represent very good agreement and Kappa values below 0.40 indicate weak agreement. Kappa values between 0.40 and 0.75 represent intermediate agreement (Fleiss, 1981). The results of this phase of the study may be observed in Table 3. The data showed excellent agreement between the nurses at the beginning and the end of shift, as the Kappa value was 0.92. It was noted that among the 28 participants who administered the instrument, 27 (96.4%) agreed to fill out the instrument at the beginning and at the end of shift and only one (3.6%) changed their answer at the end of shift. To confirm that there is correlation among nurse scores, Pearson’s
24 22
End of shift
statistically different results. As the ICU median score was 19.5, a value significantly higher than that observed at the Cardiology Unit, it seems that the ICU poses a higher risk in the tasks involved when handling patients. In order to confirm the results obtained, the difference in risk evaluation scores was also analyzed (Table 2). The Chi-square test was used to check if there were differences, with a significant association when p-value was p0.05. The data showed that there is a statistically significant difference between scores obtained in the two units studied, confirming that the instrument is able to detect risks present during patient moving and transfer procedures. At the ICU there was prevalence of the ‘‘high risk’’ (55%) and ‘‘medium risk’’ (45%) classifications, concerning evaluation of risks detected when performing these procedures. At the Cardiology Unit the opposite result was obtained. Therefore, it was demonstrated that the ‘‘low risk’’ classification prevailed (60%), followed by the ‘‘medium risk’’ (40%) classification.
20 18 16 14 12 14
16
18
20
22
24
Beginning of shift Fig. 1. Dispersion diagram of nurse scores obtained at the beginning and end of shift (r ¼ 0:92).
correlation coefficient (r) was used. The data may be seen in Fig. 1. The results indicate a positive correlation between scores obtained at the beginning and end of shift by the same nurses. Pearson’s correlation coefficient presented a value ðrÞ ¼ 0:92; considered excellent, confirming the agreement between nurses. 3.2.2. Equivalence In order to evaluate equivalence reliability the agreement between both observers, when simultaneously filling out the instrument at the beginning of shift, was verified. For analysis purposes the results of scores classified as ‘‘low’’, ‘‘medium’’ and ‘‘high’’ were used, calculating the Kappa (k) coefficient. Data are presented in Table 4. The test showed that there was good agreement between results when the instruments were administered simultaneously and to the same patient, presenting a Kappa value=0.84. It was also seen that among the 28 instruments administered by each of the observers, 26
ARTICLE IN PRESS C.A.T. Radovanovic, N.M.C. Alexandre / Applied Ergonomics 35 (2004) 321–328 Table 4 Evaluation of agreement between both observers, regarding score classification Nurse
Researcher Low risk
Medium risk
High risk
Total
n
N
N
n
Low risk Medium risk High risk
0 0 0
0 9 1
0 1 17
0 10 18
Total
0
10
18
28
Kappa = 0.84.
24
Researcher
22
20
18
16
14 14
16
18
20
22
24
Nurse Fig. 2. Dispersion diagram of nurse and researcher scores obtained at the beginning of shift (r ¼ 0:84).
participants (92.8%) agreed with the researcher when filling it out and only two participants (7.2%) disagreed with the answer on the instrument. Pearson’s correlation coefficient was used to check the existence of correlation between scores. The data may be seen in Fig. 2. Pearson’s coefficient showed a value of r ¼ 0:84; considered satisfactory and indicating there is positive correlation between the scores obtained by both observers. This test confirmed the existence of agreement between the observers. 3.2.3. Consistency In order to verify the internal consistency of the instrument items, Cronbach’s Alpha coefficient—obtained from the results of 48 instruments administered in two different hospital wards—was calculated. Estimated reliability based on internal consistency obtained a Cronbach’s Alpha total of 0.81, with coefficients varying from 0.73 to 0.87. These data showed that there is homogeneity among the instrument items.
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4. Discussion The present study validated and verified the reliability of an instrument developed to evaluate patient handling tasks, making it possible to estimate the kind of assistance required. The suggestions of the judges validating the content and the results of the pilot study made it possible to build a clearer and more objective instrument. Construct validity was evaluated using the known groups technique, which contrasts scores of groups regarded as different in relation to the studied attribute. It was demonstrated that the instrument might provide an effective evaluation of risks. It was noticed that the Intensive Care Unit patients are at a greater risk than the patients admitted to the Cardiology Unit. The instrument was able to detect the differences between wards. This was as expected, confirming the importance of an evaluation to perform tasks related to patient handling, when risks and specific patient characteristics should be taken into account. It is hoped that new research will test the instrument with different kinds of patient and health institutions. The analysis of the internal consistency evaluation showed that the instrument presents homogeneity among its items. It was not necessary to remove any item from the instrument, as the data revealed an Alpha total of 0.81, demonstrating that the instrument is reliable. Expert judgments were used for the selection of topics and weights. The instrument included eight topics that were separately analyzed. Regarding patient weight, some authors strongly recommend evaluating and planning the whole process in detail when handling obese patients, with the aid of mechanical devices whenever possible (Marras et al., 1999; Engkvist et al., 2000). In a study carried out by Alexandre and Angerami (1993), the second most frequent complaint of nurses regarding patient transportation is related to patients weight. Although the literature has not discussed the height of patients, in practice this factor may require a greater number of employees to perform tasks related to patient handling. With reference to the level of consciousness, most patients in the ICU were unconscious and highly dependent, which is considered a special problem arising in specific handling situations (National Back Pain Association, 1997). Dependent patient transfers may be one of the factors that cause work-related injuries and has been shown as a contributing factor to low back pain (Alexandre and Benatti, 1998; Engkvist et al., 1998; Owen, 2000). Experts recommend the utilization of mechanical lifting devices and auxiliary materials to minimize back compression forces and subsequent risk of back problems (Ulin et al., 1997; Marras et al., 1999; Alexandre et al., 2001).
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Concerning the topic that evaluates accessories and equipment connected to patients, a significant percentage of individuals made use of more than five accessories, which presented difficulties in transferring and moving these patients. Some authors emphasize that before starting a transfer it is important to evaluate patient conditions (Troup and Rauhala, 1987; Winkelmolen et al., 1994; Alexandre and Rogante, 2000). Several authors recommend training programs on patient transfer techniques as preventive measures to avoid back pain and injuries among nursing professionals and also to draw attention to the importance of the use of assistive devices in patient transferring and moving procedures (Zhuang et al., 1999; Marras et al., 1999; Kjellberg et al., 2000; Elford et al., 2000). The first step to begin training on adequate transfer methods is to evaluate environmental risks. Restricted physical space poses limitations to movement and is pointed out as one of the causal agents of back pain in nursing personnel (McAtamney and Corlett, 1992; McAtamney and Hignett, 1993; Botha and Bridger, 1998). McAtamney and Hignett (1993) say that risk factors should be considered in the evaluation of the workplace and equipment. Some authors discuss the importance of the use of height-adjustable beds in nursing, as this makes it easier to handle and minimizes the effort made to lift patients (Bell, 1987; Pheasant, 1987; Botha and Bridger, 1998; Caboor et al., 2000). It was considered important to evaluate all patient circumstances, such as weight, height, consciousness, dependence level (mobility, transfer and walking), accessories and equipment connected to the patient, in addition to special risks. All these topics are considered in the current instrument; other topics may be added to the instrument, according to where it will be used. The evaluation of reliability by means of test–retest stability showed that there is agreement between the scores of the same nurses who administered the instrument on two separate occasions. The data demonstrated a result of 96.4% agreement between nurse responses at the beginning and at the end of shift. Every instrument should produce identical or very similar results when administered at different times, considering the same patient. Reproducibility was evaluated first for agreement and correlation of scores measured by the same nurses at two distinct times, at the beginning and at the end of the shift. Kappa’s coefficient (p ¼ 0:92) and Pearson’s coefficient (r ¼ 0:92) results confirmed that the instrument is reproducible and reliable in a specific period of time. Equivalence reliability verified there was agreement and correlation between two different observers through the simultaneous filling out of the instrument. The evaluation of this stage was done by using
Kappa’s coefficient, which obtained a result of p ¼ 0:84; demonstrating good agreement between observers. Pearson’s coefficient, equal to r ¼ 0:84; also indicated positive correlation. By means of equivalence analysis it was verified that the instrument is easy to understand, since the results demonstrated were considered reliable. In order to conduct patient handling assessment in a health-care institution it is important to consider the specific characteristics of each unit and of its patients. The administration of the instrument developed in this research may provide a background for health care workers to make plans to provide assistance in accordance with the dependence degree and needs of each patient. The instrument may also help to follow up the evolution of the patient. Based on this planning, the health care worker will be able to define the best handling method. 4.1. Limitations of this study This instrument was tested with only two kinds of patients, according to the methodological requirements of construct validity. It is hoped that now other studies will test the instrument in other hospital locations, like orthopedic, geriatric and neurological wards. New research should be conducted extending its use to different populations. The topics that make up the instrument may also be modified in other studies, depending on the location and on the patients involved. Nonetheless, the present study will help to fill a void in this area. It is hoped that it will arouse interest on the theme and act as support for further research on the subject.
5. Conclusions A new instrument was developed to evaluate patient handling. Construct validity presented a significant difference between both units studied, demonstrating that the instrument was able to detect these differences. The internal consistency analyzed by Cronbach’s Alpha coefficient demonstrated that the instrument presents homogeneity of components. The stability test, evaluated by administration of the instrument by the same nurses at two different moments demonstrated excellent agreement, through the Kappa coefficient result. There was also positive correlation shown by the data obtained by Pearson’s coefficient. Equivalence was evaluated by simultaneous administration of the instrument by two observers and analyzed by Kappa and Pearson’s coefficients. It was demonstrated that there was satisfactory agreement between the observers.
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The results indicated that the instrument is viable and that it may contribute to a better planning of nursing assistance, together with other preventive ergonomic strategies. The instrument may help health care workers to systematically plan the level of assistance needed.
Acknowledgements The authors wish to thank Rosaly Davis for editing the manuscript. Appendix A
PATIENT HANDLING ASSESSMENT FORM Name: Ward: Admission date:
Age: Bed: Diagnosis:
Mark a value from 1 to 3 according to the evaluation of each item. Data Weight
Height
Level of consciousness
Mobility in bed
Transfer
Walking
Catheters and equipment
Special risks
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Concepts Up to 50 Kg 51– 69 Kg > 70 Kg Up to 1.50 m 1.51- 1.79 m > 1.80 m Alertness Confusion/lethargy Unconsciousness/restlessness Independent Able to move with assistance Dependent Independent Able to transfer with assistance Dependent Independent Able to walk with assistance Dependent Up to 1 2 to 4 accessories + 5 accessories Good Risk potential Risk
Points
Days in hospital
1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3
Total Record scores and the level of assistance needed: 08-12 = “Low risk”= No assistance necessary. Supervision required. 13-18 = “Medium risk” = Patient may need assistance, some kind of handling aid or selected technique. 19-24 = “High risk” = Seek assistance, selected hoist or other appropriate handling aid.
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