Positioning

In order to practice good positioning, it is necessary to understand how it is used and the benefits it affords. Variations in position will allow the child to be comfortable and ease the pressure exerted on any one area. Changing positions will help prevent the skin becoming sore or breaking down and the subsequent pain and limitation of movement which might result. Certain positions can be used to help facilitate play. Allowing the child to experience movement in a range of different positions encourages normal development (Bly 1994). Specific positioning may be an important part of training a child to feed by ensuring correct head-on-body alignment. Positioning can assist the child with respiratory difficulties to drain secretions or reduce the work of breathing (Hough 1984, Badr et al 2002, Harcombe 2004). Positioning can have an influence on an infant’s ability to lose heat and on the speed of gastric emptying (Hallsworth 1995). Children who have limited ability in movement need regular alterations to their positions in order to prevent the formation of muscle contractures and deformities (Dubowitz 1969, Goldspink et al 2002). It has also been shown that children with abnormal movement patterns and involuntary movements can have their problems reduced by correct positioning (Finnie 1997).

Moving and handling

It is important to understand the potential risks associated with incorrect positioning and poor posture to both the child and the carer. The risks of musculoskeletal problems to which all who work with children are exposed should be recognised, whether they come from continual lifting, stooping or working at an awkward level (Alexander 1997). Musculoskeletal injuries can be any injury which affects the musculoskeletal system but the most frequently seen injury resulting in work absence in the UK is back pain (Dolan & Adams 2005). Furthermore, it is estimated that four out of every five adults (80%) will experience back pain at some stage in their life (Maniadakis and Gray 2000). It is estimated that back pain along with stress is the biggest cause of sickness absence in the NHS, with a staggering 40% of this leave being attributed to back pain (HSE 2008). The prevalence of musculoskeletal injuries is further compounded by a lack of risk assessment being undertaken (CSP) in 2005 (cited in Glover et al 2005). The consequences of losing experienced professionals is obvious but the broader picture shows a huge financial burden on the healthcare sector to care and treat these injured individuals. It is estimated that every year, the healthcare sector spends on average £1.6 billion treating individuals with back-related pain, many of whom are injured healthcare professionals (Maniadakis & Gray 2000). In particular, a study carried out by The Chartered Society of Physiotherapy (CSP) in 2005 estimated that 67.5% of physiotherapists reported career prevalence of work-related musculoskeletal injuries (CSP, 2005).

Although much of the moving and handling literature focuses on preventing injury to the carer, it is imperative that the patient does not sustain an injury as the result of these activities; a commonly forgotten misconception. The incorrect handling of children can cause undue distress to the child and if handled with controversial handling techniques, can cause discomfort and injury to the child. Over time, experts in the field of moving and handling have advised against the use of uncomfortable and high risk handling techniques, because of the risk of sustaining an injury to the handlers (Ruszala 2005). As more evidence is presented, these controversial techniques are updated. It is the responsibility of any healthcare professional working with patients to ensure that their practice reflects this evidence-based practice as stated in the professional Codes of Conducts. These controversial techniques include, but are not limited to, the orthodox lift, the through-arm lift, the Australian lift, the front assisted transfer (also known as the bear hug and clinging ivy), and the drag lift (Ruszala 2005). Although the use of patient handling belts and handling slings have been very popular in the past, these handling aids are not advisable within children’s nursing due to the poor posture and damage they can cause to both the child and the carer. It is worth noting that in some situations, physiotherapists and rehabilitation professionals will use both adapted front assisted transfers and handling belts to assist the handling of some children. These practitioners have received a greater depth of training in these practices compared with nursing practitioners and will use detailed risk assessments to reduce the risks associated with these practices. Indeed, Mutch (2004) suggests that the main difference between therapists and handlers is the observation method, in which handlers develop their specialist techniques compared with the specialist training the therapists receive. The Moving and Handling Advisor within each healthcare setting will be best placed to update and inform professionals on these techniques.

Healthcare Professionals must comply with the relevant legislation within this field of practice paying particular attention to the requirements of The Children’s Act (HMSO 1989); The Human Rights Act (HMSO 1998); and the Disability Discrimination Act (HMSO 1995/2005) to ensure that any treatment encompasses the holistic needs of the child.

In order to reduce the risks associated with poor posture and handling techniques, it is imperative that appropriate risk assessments are conducted prior to carrying out any moving and handling activity. The Manual Handling Operations Regulations (as amended) (HMSO 1992), identify a specific approach to risk assessing a manual handling activity which can be applied to both animate and inanimate load handling. In summary, the employees’ responsibilities are:

In order to undertake a risk assessment, there are many factors that must be taken into account. These can generally be classified into five categories as follows:

Once these risks have been identified the employee must work to reduce these risks where reasonably practicable. This may include using handling equipment to assist with the activity.

When participating in moving and handling activities, healthcare professionals must ensure that they adhere to the legislative framework concerning paediatric care. In particular, consideration must be taken with regard to the informed consent process. Those healthcare professionals working in the paediatric setting must ensure that they act as advocates for the child or young person with whom they are working (CSP 2008).

There are a wide range of moving and handling aids currently available within the healthcare market. This equipment is designed, when used appropriately, to minimise the risk of injuries to both patient and carer, associated with handling patients. Each healthcare provider must carry out a detailed risk assessment to identify the most appropriate moving and handling aids to suit the needs of the client or patient group for which they care. It is important to ensure that there are adequate supplies of this equipment available to meet the needs of the patient group.

The most commonly used handling equipment include mobile and ceiling track hoists, low friction sheets, transfer boards, hand blocks and standing aids. There are many different types of hoist, all of which will facilitate a varying degree of movement for the patient. For example, there are hoists available which can facilitate safe walking with the more able patient and some hoists which will facilitate the patient to stand up supported. A walking hoist or standing hoist will require the individual patient to have an appropriate degree of ability and strength to facilitate these movements. However, the most commonly used hoists are generally used to move the dependent patient and do not require the patient to have any ability in order to facilitate their movement. Furthermore, this type of hoist will be able to move the patient in a prone position, a reclined position or a seated position depending on the type of hoist sling and hoist attachments used.

The patient sling can be professionally altered to meet the tailored needs of the patient, ensuring their safety throughout the hoisting activity. When considering children, additional safety belts and head supports are often featured on paediatric slings to maximise both comfort and safety for the child. Furthermore, slings designed for children are often colourful and incorporate features which will appeal to the younger patient; for example slings in the design of a popular children’s cartoon character or specially designed fabric which will attract the younger child.

Orchard (2005) suggests that the key to successful and comfortable hoist transfers lies in the correct fitting of the sling, both in terms of size and type. The patient sling can be designed to meet the needs of individual patients and most popularly include features which facilitate patients to carry out tasks equivalent to toileting, bathing, walking and standing where the hoist can accommodate this. With such variety, it is imperative that a thorough risk assessment is carried out to ensure the correct selection of the sling is made for the various activities required by the patient. In addition, slings come in varying sizes, weight limits and fabrics and this needs to be taken into account when choosing the most appropriate sling for use.

Low friction sheets (more commonly known as slide sheets) are used to facilitate patients to move while in bed by reducing the friction between the slide sheets and allowing the top sheet to slide over the bottom sheet. Two main types exist in today’s market; roller/cylinder sheets and flat sheets, which are required to be used in pairs. Both use the same principles to allow patients to move and turn while in a prone position. Low friction sheets can be used with a variety of dependency patients and are a valuable resource in both the hospital and community setting. It is worth noting, however, that low friction sheets should never be used with patients with a suspected or confirmed spinal or head injury due to the unpredictable movement associated with this equipment. A smaller version of the low friction roller sheet designed to lock in position in a single direction is invaluable with patients who slide down the seat of a chair and are very popular with younger children who cannot reach the floor with their feet when sitting down.

Transfer boards are available in a wide variety of shapes and sizes and are designed to facilitate safe assisted transfers for patients. Undoubtedly the most renowned transfer board is the PATslide which is commonly used for the transfer of the prone patient from one surface to another. Commonly available in the Emergency Department and Intensive Care settings, this transfer board can be used for the unconscious patient and is often used for transferring patients between beds/trolleys. More recently, the use of slide sheets with the transfer board has proved a very successful combination among the moving and handling community.

Smaller transfer boards are designed to assist patients to transfer between two surfaces in an upright sitting position by acting as a bridge between the two surfaces. These patients require adequate strength within their arms and upper body to facilitate their movement. Those patients who have weakness in their lower limbs can use a turn disc placed beneath their feet to allow their feet to follow the direction of their moving body. As with any moving and handling aid, a thorough risk assessment is required to ensure that the patient is both capable and safe to use with this type of transfer board. Although some patients will safely be proficient at using the transfer board independently, the majority of patients will require supervision and support to use this equipment. In particular, children are often anxious about using the transfer board initially but adapt very well to this equipment which facilitates much independence. The patient’s handling plan and risk assessment will direct this. For some children, play specialists may be able to help in reducing this anxiety and facilitating compliance with this handling activity through structured play.

Moving and handling equipment is designed to meet the needs of the dependent patient to the semi-independent patient. It is therefore important that the most appropriate equipment is used to ensure that the needs of the patient are met without over-riding their own ability or independence. As with all patient activities, the patient should be encouraged and empowered to participate in the activity when they are able and it is appropriate to do so. As a patient progresses and becomes more independent it may be necessary to reduce the support offered by moving and handling aids to encourage their own independence. The healthcare professional must ensure that the risk assessment and subsequent treatment plan is reviewed and updated on a regular basis to reflect these changes in the patient’s condition and ability (CSP 2008).

As with any piece of equipment, it is important that those using the equipment are trained in its correct use and are competent to use it safely. This training needs to take place with the involvement of specially trained advisors to ensure that the users receive the most appropriate advice on each piece of equipment and are aware of the requirements of the moving and handling aids.

It is important that all moving and handling aids are kept clean in accordance with the manufacturer’s instructions and the recommendations of the infection prevention and control guidance applicable to each individual place of work. Disposable low friction sheets and slings can be obtained for use with the infectious patient. Likewise, all equipment should be well maintained and in good working order, and that appropriate measures are taken to ensure their safe use. All equipment is covered by the Provision and Use of Working Equipment Regulations (HMSO 1998) which details how equipment must be maintained and kept safe. Similarly, the Lifting Operations and Lifting Equipment Regulations (HMSO 1998) inform the user about maintenance and servicing requirements of all patient hoists and slings.

It is important to note that this is only a brief guide to risk assessment and that each employer will have its own local code of practice with which its employees have a duty to cooperate (RCN 1993). Furthermore, when considering patient handling, a patient handling plan identifying the various risks must be completed in line with the employer’s guidelines to direct the type of equipment and technique used to assist the patient to move. In addition, when caring for children, the child and family must be consulted and involved in the handling plan and should be kept updated on the child’s progress throughout their care in line with the philosophy of family centred care.