To lift or not to lift: an institutional ethnography of patient handling

Abstract

The handling (lifting, mobilizing, moving etc) of patients is an integral part of the carework in health-care institutions. For obvious reasons, this puts healthcare providers at risk for musculoskeletal injuries (MSIs); furthermore the risk of such injuries has been considered an inherent risk of care work. In the last decade a concerted effort has been made to decrease (with the goal of eliminating) caregiver injuries by implementing safe patient handling programs (SPHP). These programs are presented as evidence-based algorithms that require the use of mechanical lifting devices. Institutions implement SPHPs as policies and procedural guidelines to which caregivers must conform. SPHPs represent a change in institutional thinking from the earlier belief that MSIs were inherent to care work, to the contemporary idea that injuries are preventable. Despite these efforts, healthcare providers continue to be exposed to the risk of injury. The assumptions underlying the SPHP are open to questions, none of which are addressed in the literature. Most importantly the literature does not take into consideration that healthcare providers are handling individual patients with subjective and unique needs. For the purpose of understanding why healthcare providers continue to be exposed to the risk of MSIs, the purpose of this study is to explore how the generic policies and guidelines meant to apply to all patient-caregiver interactions impact patients and caregivers in everyday care work. In particular, this study examines the complexity of care delivery on inpatient care units that have implemented the latest research recommendations regarding safe patient handling. This study starts with the assumption that care workers are positioned at the intersection between the patient and the hospital policies and guidelines that govern their care. In order to understand the caregivers' continued exposure to injury, this study examines the work of caregivers during their shift and the policies and guidelines they encounter that impact their decisions. This study is an Institutional Ethnography (IE), a unique research approach that makes visible how complex actions in everyday care work are coordinated by institutional texts such as policies and guidelines. This research approach permits the researcher to make visible the connection between the actual day-to-day experiences of people and the organizational priorities as reflected in institutional texts. This study was conducted in two healthcare facilities on neurology and rehabilitation units which had instituted SPHPs and had state-of-the-art lifting equipment. Two sources of data were collected for this study, the first were observations of every day lifting. It describes caregiver practice beginning with 1. A description of how caregivers obtain the knowledge they need to handle the patients encountered during their shift. 2. What occurs once the caregiver encounters the patient. 3. Their decision-making process used to determine how to transfer a patient. 4. How the transfers are brought into action, and 5. How this care is then documented and reflected in the patient's record. The second source of data were the institutional texts that impacted the handling of patients. These were identified by interviewing caregivers and managers and performing searches in institutional data