RESEARCH

REDUCING PATIENT HANDLING INJURIES

THROUGH CONTEXTUAL TRAINING
Authors: Marc L. Resnick, PhD, and Roderick Sanchez, OTR, MS, Miami, FL

Earn Up to 8.5 CE Hours. See page 597.

J Emerg Nurs 2009;35:504-8.

positions, producing extreme postures and using their

own skill and strength. This approach to manually handling patients creates inconsistency among nurses and
places the patient and nurse at risk for harm. In 2004, hospitals reported 284,600 employee injuries, and nursing and
residential care facilities reported 215,200 employee injuries related to manually handling patients. Nurses have
the highest rate of back pain, with an annual incidence of
40% to 50% and a lifetime occurrence of 35% to 80%.1
The American Nursing Association claims that manual
patient handling is unsafe and is directly responsible for
musculoskeletal disorders among nurses. Demographic
trends compound this problem: Patients are getting heavier2
and nurses are getting older.3
The health care industry has many choices when it
comes to supporting safe lifting among nurses. Hospitals
need to decide on an appropriate training format and content and whether to provide lift support equipment to
nurses. Administrators should base these decisions on the
realities of the emergency care domain, especially given
the high cost of failing to adequately train nurses. Research
reveals that current interventions, such as classroom training, lift teams, and the use of lift assist devices, have failed
to reduce job-related injuries when applied independently.4
Instead, hospitals need to develop a comprehensive ergonomic approach.
The pressure-filled environment of emergency care
adds to this challenge. Time pressure is often a factor
because the longer it takes to move the patient, the
worse the patients condition may become. The pressure
on the nurses to act quickly may lead them to revert to
inappropriate postures used before training and to move
independently instead of as a team. Also, during an
emergency it is easy to become distracted or focus too
hard on the patient and forget a step of the safe handling method. These challenges illustrate the importance
of effective training that can be applied in the hectic
health care setting.

Available online 24 February 2009.

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Training Formats

Introduction: In the United States there is no standardized

method for training emergency nurses in manual patient handling,
despite the high incidence of injury. The objective of this research
was to evaluate several training protocols, including the use of
simulated emergency situations and the use of realistic context
during course delivery, to evaluate their impact on nurses postures
and compliance with trained procedures during post-training tests.
Methods: Sixteen nurses were trained in 1 of 4 training

protocols. Pre-training and post-training patient handling tasks

were observed. Nurses torso postures were evaluated using a
modified Standard Posture Classification System, and their
compliance with a set of trained safe practices was monitored.
Results: All forms of training significantly improved the nurses
torso flexion and rotation and compliance with safe patient
handling practices. Contextual training led to the greatest
improvements on all measures.
Discussion: The results show that hospitals can reduce the risk

of back injury among emergency nurses due to patient handling

through specific training in patient handling. The use of contextual
training formats reduces injury risk significantly more than does
classroom training.
Key words: Patient handling; Ergonomics; Training; Safe practices

mergency nurses are required to perform physical

tasks that are considered complex, unplanned,
and often unpredictable. They are required to move
and lift patients from various heights and from awkward

Marc L. Resnick is Associate Professor, Industrial and Systems Engineering

Department, Florida International University, Miami, FL.
Roderick Sanchez is Research Assistant, Industrial and Systems Engineering
Department, Florida International University, Miami, FL.
For correspondence, write: Marc L. Resnick, PhD, Industrial and Systems
Engineering Department, Florida International University, Miami, FL
33199; E-mail: resnickm@fiu.edu.

Copyright 2009 Emergency Nurses Association. Published by Elsevier Inc.

All rights reserved.
doi: 10.1016/j.jen.2008.10.017

Training in patient handling often is not provided in a

systematic way. Body mechanics training courses may be

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RESEARCH/Resnick and Sanchez

offered as a solution for the ongoing problem, but these

courses typically follow a classroom format. Classes are held
off the unit in a conference room or in an unoccupied
patient room. These types of learning environments may
not be conducive to applying body mechanics principles in
complex and hectic settings. Knowledge acquired in a classroom setting does not always transfer directly to competent
behaviors or appropriate use.
On the other hand, contextual training is designed
specifically to address the challenge of transfer. It involves
creating realistic scenarios in which nurses can apply what
they are learning. This context is important because training that is easy to apply in a generic classroom may not be
so simple to apply in the real world. Contextual training
attempts to simulate important characteristics of the real
world so that when nurses need to lift real patients, they
can apply the training without having to figure out how
to translate it themselves.

draped across the middle. All teams were given the same
verbal instructions.
TRAINING PROTOCOLS

Methods

Four training protocols, corresponding to a 2 2 factorial

combination of the use of classroom and contextual training
and the use of emergency and non-emergency situations,
were provided as part of an existing course in the nursing
program. Participants were assigned to 1 of the 4 training
protocols. Within each condition, participants were organized into teams of 4 to match the typical patient handling
team in an operating room, with one person at the front,
left, and right sides of the table and one acting as the patient.
The patient-handling task was repeated 4 times, giving each
participant the opportunity to handle the patient in all
4 roles. A video recorder was placed at the foot of the bed
to record their postures and behaviors.
In the classroom condition, participants were trained
in a traditional classroom environment and were allowed
30 minutes of practice time after the training. In the contextual condition, participants practiced moving each
other. A scenario was described requiring the participants
to reposition and turn one another. Each participant had
the opportunity to slide the patient to the head of the table
and turn the patient onto his or her side. Following the
training, 30 minutes of practice time was allowed.
In the emergency condition, the practice sessions were
conducted either under strict time pressure or by using display monitors to create a stressful scenario. In the nonemergency conditions, participants were allowed as much
time as needed to complete the tasks.

PARTICIPANTS

POST-TRAINING TEST

Study Objective

The objective of this study was to evaluate the benefits of

contextual training formats and emergency situational
training on safety for nurses backs. Context was used to
reproduce the complex requirements of the emergency
department. An emergency situation was used to simulate
time pressure. These training methods seem to have the
best potential for maximizing the transfer of safe lifting
to actual health care settings.

Sixteen participants were recruited from the Nursing Program at Florida International University. They were taking
a course in Clinical Care and Emergency Room Experience. Participants included 10 female and 6 male nurses,
with a mean age of 33 years and an average of 5 years of
nursing experience. Participant heights ranged from
60 inches to 73 inches with a mean of 70 inches. There
was wide variation in participants history of back pain and
previous training in patient handling. The study received
approval from the University Institutional Review Board.
PRE-TRAINING TEST

The post-training test took place 1 week after the training

session. Participants were given a scenario where the patient
had been given too much anesthesia and was unable to assist.
Utilizing sound and a display monitor, the nurses were able
to hear the patients heart beating faster and see the heart rate
increase as the oxygen saturation decreased. Torso postures
were again video recorded. Each group performed the scenario 4 times, allowing all the participants to role play as
the patient and be at the head and on both sides of the table.
PERFORMANCE INDICATORS

A pre-training test was used to establish a baseline for all

of the performance measures. The test took place in a
simulated operating room with an operating room table
and surrounding equipment typical of that found in a
hospital. The height of the table was adjustable and
the arm rests were removable. The table was dressed
with clean linen, and a friction-reducing sheet was

Standard Posture Classification System

A modified version of the Standard Posture Classification
System was used to measure trunk flexion and rotation.5
The Standard Posture Classification System is a scaled
observation tool that categorizes postures from 0 (neutral)
to 3 (severe) based on severity. Ratings greater than 1.0
may indicate an elevated risk of injury.

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1. Preparing the environment, which included adjusting the

height of the bed, removing the table arm rests, and using
friction reducing sheets;
2. Identifying a leader to assess when the patient is ready to
be moved, provide head support, and control the airway if
the patient is intubated; and
3. Communicating the process among the team when positioning the patient, using a script that was provided during training.
Results

POSTURE

Training had a significant effect on flexion (F = 159, P < .001)

and rotation (F = 48, P < .001). Before training, ratings of
torso flexion averaged 2.5 on the modified scale compared
with 1.0 during the post-training test. Similarly, ratings of
torso rotation decreased from 2.1 before training to 0.6 after
training (Figure 1). None of the co-variants (participant sex,
height, and work experience) significantly affected the postures observed.
The type of training had a significant effect on flexion
(F = 14.354, P < .001) and rotation (F = 15.534, P < .001).
Contextual training was more effective than classroom
training in reducing awkward postures (Figure 2). The
mean rating of torso flexion for contextual training
decreased from 2.4 before training to 0.7 after training.
Mean ratings of torso flexion for the classroom training
decreased from 2.5 before training to only 1.3 after training. The same effects were observed for torso rotation.
There was a decrease in mean ratings of torso rotation in
the contextual training group from 2.1 before training to
0.4 after training. In the classroom training group, mean
ratings of torso rotation only decreased from 2.1 before
training to 0.9 after training.
The training situation had no main effect on flexion
(F = 2.835, P = .103) or on rotation (F = 0.767, P = .389).
Both emergency and non-emergency training elicited about
the same improvement in torso flexion and rotation (Figure 2). The mean ratings of torso flexion after emergency
training decreased from 2.4 before training to 0.9 after
training. The mean ratings of torso flexion after nonemergency training decreased from 2.6 before training to
1.1 after training. The mean ratings of torso rotation in

506

4.0
Mean Rating

Task Analysis
Participants were evaluated according to whether they followed the safe methods for patient handling that were presented during training. The methods they used were
observed, and compliance with each step was recorded.
There were 3 procedural categories:

3.0
2.0
1.0
0.0

PrePostTraining Training
Flexion Flexion

PrePostTraining Training
Rotation Rotation

FIGURE 1
Mean ratings of torso flexion and rotation on the modified Standard Posture
Classification System Scale pre-training and post-training.

emergency training decreased from 2.2 before training to

0.6 after training. The mean ratings of torso rotation after
non-emergency training decreased from 2.0 before training
to 0.7 after training.
USE OF SAFE PRACTICES

Training also had a significant effect on the use of the

safe practices covered during the training session (Table).
Before training, none of the participants prepared the
environment, 78% identified a team leader, and 81% communicated the process. In the post-training tests, 94% prepared the environment, 97% identified a leader, and 97%
communicated the process. All 3 of these differences were
significant (2 = 119.03, P < .001).
There was also a significant advantage of contextual
training on use of the safe practices covered in the training
session. After contextual training, all participants complied
with all 3 components of the trained methods. After classroom training only 88% of participants complied with
preparing the environment and 94% complied with identifying a leader and communicating the process. This difference was significant (2 = 4.17, P = .04).
The training situation had no significant effect on
compliance with the safe practices (2 = 0.34, P = .557).
After emergency training, 94% of the participants complied
with the trained method for preparing the environment and
communicating the process, and 100% of the participants
complied with identifying a leader. After non-emergency
training, 100% of the participants complied with communicating the process and 94% complied with both preparing
the environment and identifying a leader.
Discussion

This study focused on the evaluation of patient-handling

training practices that can be effective in the domain of

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RESEARCH/Resnick and Sanchez

1.5

Mean Rating

Mean Rating

1.5

1.0

0.5

0.0

1.0

0.5

0.0
Contextual Classroom
Flexion
Flexion

Contextual Classroom
Rotation Rotation

Non
Emergency emergency
Rotation Rotation

Non
Emergency emergency
Flexion
Flexion

a) classroom versus contextual

b) emergency versus non-emergency

FIGURE 2
Mean ratings of torso flexion and rotation on the modified Standard Posture Classification System Scale for post-training observation.

TABLE

Compliance with trained safe procedures before training and in each post-training condition
Post-Training

Preparing the environment

Identifying a leader
Communicating the process

Pre-training
(%)

Post-training
(%)

Contextual
(%)

Classroom
(%)

Emergency
(%)

Non-emergency
(%)

0
78
81

94
97
97

100
100
100

88
94
94

94
100
94

94
94
100

emergency care. Proper body mechanics are critical for reducing the incidence of back injuries in ED nurses due to
patient handling. The effects of context and simulating a
patient emergency were targeted because of the challenges
that these place on emergency nurses.

process and identifying a leader was somewhat intuitive

even without training, after the training virtually all participants used all 3 safe practices.
CONTEXTUAL VERSUS CLASSROOM

The results show that training in general had a significant

effect on the flexion and rotation postures that participants
used to turn the patient. Training brought the postures
from levels that have a high risk of injury to levels with a
significantly lower risk. Therefore, providing training in
proper body mechanics is critical for reducing the incidence
of back injury in nurses due to patient handling. The training protocol used here provided a standardized technique
that nurses were able to apply to patients, as simulated
by their co-trainees. This facilitated later recall and application during the post-training test. The training also provided participants with a set of easy-to-remember safe
practices that minimize risk. While communicating the

Contextual training provided a greater improvement on

both torso posture and compliance with safe practices than
did classroom training. After contextual training, the torso
postures participants used were close to neutral, and 100%
of the nurses complied with the trained practices. This
result is likely because contextual training allowed the
participants to place their hands on the friction-reducing
sheets and practice during the didactic section of the training. The contextual training allowed participants to experience the techniques while they were being explained.
Although 94% of the nurses in the classroom group complied, back injuries are expensive and have long recovery
durations. Even a small but statistically significant improvement in compliance could result in millions of avoided
injuries if extrapolated across the health care industry.

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RESEARCH/Resnick and Sanchez

EMERGENCY VERSUS NON-EMERGENCY

There was no significant difference in the effect of training on

torso posture between the emergency and non-emergency
groups. For the posture observations, the trend showed an
advantage for emergency training, so this lack of significance
may be a result of the small sample size. Compliance with
trained safe practices saw a ceiling effect. Virtually all participants complied with the safe practices in both groups.
Non-emergency training is widely used in hospitals during
annual nursing competencies to allow nurses to experience
proper body mechanic techniques without the cost of a
simulation module. But in one study,6 participants viewed
experience as the most important factor influencing competent development of patient-handling techniques and
reported that it prepared them to provide a high standard
of care. Thus, simulating emergencies during training may
still provide significant value.

nificantly improved the torso postures that they used to

turn a patient and increased compliance with safe lifting
practices. Training emergency nurses in this way can
reduce the risk of back injuries during patient handling.
The results of this study also show that contextual training
leads to a greater improvement in torso posture than does
classroom training. Health care organizations need to individualize training and nursing competencies to provide
relevant context.
Conclusions

The high incidence of back injuries during patient handling and the resulting financial and human costs to emergency nurses warrant continuing investigation to identify
the most effective training interventions.1 Emergency care
providers must offer training that minimizes the risk of injury to nurses and can be transferred to the hectic and complex environment of the emergency department.

Limitations

This study investigated the effects of 2 training interventions: using contextual training and simulating emergencies. Because patient handling in an emergency room is
typically complex and time pressured, these interventions
seem to provide the best opportunity for improvement.
However, other interventions that were not tested may
exist that also could provide improvements. In addition,
several other types of patient-handling equipment are used
in hospital settings. This equipment was not investigated in
the present study. Although the use of 16 participants was
sufficient to identify statistically significant differences
between classroom and contextual training, more participants could have identified significant differences in the
emergency and non-emergency conditions.

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Training participants on the proper use of body mechanics,

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