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4 04/07/2021

Translating Safe Patient Handling and Mobility Curriculum into Clinical Practice: Clinical
Education Experiences of Doctoral of Physical Therapy Students

Authors: Darie Kirschling & Summer Demeuse

Research Advisor: Dr. Jamie Haines, PT, DScPT

Doctoral Program in Physical Therapy

Central Michigan University
Mount Pleasant, MI
April 14, 2021

Submitted to the Faculty of the

Doctoral Program in Physical Therapy at
Central Michigan University
In partial fulfillment of the requirements of the
Doctorate of Physical Therapy

Accepted by the Faculty Research Advisor

Jamie Haines, PT, DScPT

Dr. Jamie Haines, PT, DScPT
Date of Approval: April 10, 2021
v.4 04/07/2021

Abstract

Introduction: The APTA recognizes physical therapists (PTs) as the leaders in

advocating for Safe Patient Handling and Mobility (SPHM) principles.1 SPHM principles and

equipment are not an embedded part of most Doctor of Physical Therapy (DPT) programs

despite research on student injury with manual handling of patients2 and the equipment’s ability

to offer therapeutic activity options earlier and more often.3 Students enrolled in DPT programs

that include SPHM curriculum have positive attitudes regarding SPHM in clinical education and

post-graduation.3 Central Michigan University’s DPT program incorporates a SPHM curriculum

embedded across all three years of the program. Purpose: The purpose of this study was to

examine how a SPHM curriculum transferred to clinical practice during Doctoral of Physical

therapy students’ final clinical education experiences. Subjects/Methods: Sixteen third year DPT

students who completed their final clinical education experiences were recruited via email on a

volunteer basis to participate in an open-ended interview. Once interviews were completed,

identifiable data was removed, and a constant comparative analysis method was used to develop

consensus of three main themes. Results: Students reported they could 1) identify when SPHM

principles and equipment could be applied during rehabilitation, 2) advocate for SPHM

principles when appropriate and 3) recognize barriers to integrating SPHM knowledge into

clinical practice. Discussion: Embedding a SPHM curriculum throughout the program helped

students' value and appreciate the role that SPHM knowledge can play during physical therapy

practice. Repeated exposure with focus on hands on learning accommodated various learning

styles within the DPT program and appeared to be a key factor in utilizing and advocating for

SPHM principles and equipment in final clinical education experiences. Conclusion: Overall,
v.4 04/07/2021

this curriculum appeared to provide the foundation for students to confidently use and advocate

for SPHM principles and equipment in the clinical setting especially in subacute, acute care, and

inpatient rehab settings.

Introduction

The American Physical Therapy Association (APTA) expects physical therapists (PTs) to

lead the effort in promoting use of and advocating for safe patient handling and mobility

(SPHM) principles.1 While SPHM principles significantly reduce the risk of injury to PTs2 and

promote early, safe mobility during recovery,3 teaching SPHM principles is not part of most

physical therapist educational programs. Research shows that manually handling dependent

patients is one of the most common causes of musculoskeletal injury in therapists,4 however,

body mechanics training continues to be taught as ‘best practice’ in most PT programs in the

US.4 Faculty cite crowded curriculum, lack of knowledge for this content and lack of access to

equipment for use in class as barriers to integrating SPHM into didactic coursework.4

Educational programs that incorporate SPHM content have shown promising results for

clinical practice.2 One study found that 37% of students enrolled in PT programs that included

SPHM content had intentions to seek out devices in facilities with SPHM policies during clinical

rotations.4 While this study reports students' intentions to use this knowledge, few studies have

examined DPT students’ experiences with SPHM content in clinical education. The Doctor of

Physical Therapy Program at Central Michigan University intentionally developed an embedded

SPHM curriculum with the goal to positively influence students’ attitudes and confidence to

integrate SPHM principles into clinical education experience. The purpose of this study was to

examine PT students’ final clinical education experiences in translating SPHM knowledge into

clinical practice.

Review of Literature

The American Physical Therapy Association supports the use of SPHM equipment and

strives for PTs to be leaders when modeling the appropriate use of this equipment.1 Other

1
organizations, including the Occupational Safety and Health Administration and the National

Institute of Occupational Safety, recommend participation in programs that educate PTs on how

to mobilize patients with equipment that reduces worker injuries and ensures patient safety.5

SPHM programs and equipment reduce health care worker risk of injury during manual handling

of patients2 and increase potential rehabilitation options for the PTs.6 Therapists can mobilize

more dependent patients to improve functional mobility including transfer training, functional

ambulation, and facilitation of bed mobility.6 While performing functional mobility tasks, the

therapists report feeling that patients were safer with the devices because there was reduced risk

of falls.6 Ideally, new graduates would be comfortable utilizing SPHM knowledge to reduce

therapist injury, improve patient safety, and maximize patient outcomes.

Education about SPHM principles and use of equipment provided to future healthcare

professionals across disciplines is not comprehensive. A study by Slusser et al. reports that 86%

of therapy programs say their curriculum is updated when necessary, to introduce new, effective

equipment to support evidence-based practice.7 Only 36% of these programs report including

SPHM equipment and concepts into the didactic portion of their curriculums.7 Other healthcare

professions such as occupational therapy and nursing promote primarily traditional manual

patient handling; very few taught safe patient handling concepts or how to incorporate it into

patient care.8,9 To prepare PT graduates to be leaders in education and use of SPHM principles,

Perlow states, “PT educators can influence future attitudes and practice by preparing student PTs

to make sound clinical decisions about the use of both manual and mechanically assisted patient

mobility.”10

In healthcare programs that do teach SPHM concepts, a multi-modal approach has been

used to incorporate this content in the curriculum.10,11,12,13 This includes lecture-based material,

2
practical skills check offs with professors, practical applications in real life scenarios,

independent study, additional online interactive videos, and education on evidence-based

research.10,14,15,16 Haines and Arnold recommend that SPHM content be threaded through DPT

programs and that students have continuous access to equipment; just as walkers and other

assistive devices are available for treatment and plan of care.5 The authors also recommend that

repetitive hands-on opportunities be available for students to explore, practice and integrate the

equipment into interventions across classes.5 Perez suggests developing learning activities via an

andragogical, multi-modal approach that encourages participation in group work and

engagement in learning to improve confidence with SPHM material.12 In addition, Plack

emphasizes the importance of meaningful participation in the clinical setting to understand what

essential qualities for SPHM are required to practice as a new PT.17 In addition, Stevenson

identifies a practice gap between what students are learning in the classroom and what they are

experiencing in the clinic pertaining to SPHM knowledge.2 Students cite clinical instructor

reluctance, culture of facility, and lack of knowledge by clinic staff as barriers to using SPHM

principles in clinical settings.2

Currently, there are few specific guidelines to inform DPT schools how to integrate

SPHM content into the curriculum. Haines and Arnold provide linkage between SPHM content,

the Normative Model criteria, Physical Therapist Code of Ethics, and CAPTE accreditation

standards.5 Eight relevant professional practice expectations have been identified from these

documents and linked with SPHM content: clinical reasoning, applying current knowledge,

accountability, safety, implementation of interventions, risk management, legal and professional

obligations, and organizational behaviors that benefit patients.5,18

3
 Central Michigan University's Doctor of Physical Therapy (DPT) Program exposes

students to SPHM content across all three years of the DPT curriculum. The SPHM curriculum

was designed to align with the Professional Practice Expectations from the Normative Model,

Commission on Accreditation in Physical Therapy Education Evaluative Criteria, and Physical

Therapist Code of Ethics.1,5,19 Utilizing Bloom’s taxonomy for learning,20 the curriculum begins

with foundational activities and expands to higher level learning. The overarching goal of the

embedded 3-year curriculum is to facilitate student behavior change that translates into clinical

practice. The Integrated Behavioral Model (IBM) provides the framework for instructional

activities and assessment of curricular impact.18 The IBM identifies factors that directly affect

behavior and include behavioral intention, knowledge and skills, saliency, environmental

constraints, experience, and habit.18 As Perez suggests, learning activities are developed to

encourage participation and engagement with an andragogical approach to improve confidence

with the material.12 Attention to various learning styles of the students serves as additional

support for activities.12 The DPT program provides continuous access to a variety of SPHM

equipment including four powered floor-based sit to stand/gait devices, one non-powered

stand/gait device, a portable overhead X-Y full-body lift, a thirty-foot straight ceiling track with

unweighting capabilities, a body weight supported treadmill system, a variety of slings/harnesses

and friction reducing sheets. The exposure students have to SPHM equipment during the didactic

portion of their education was designed to positively shape attitudes, beliefs, and values

surrounding SPHM and drive intentions of students to use these principles and equipment during

their final clinical education experiences.

4
Subjects

All third year DPT students were eligible to participate in interviews as they had

completed mandatory SPHM education during the didactic portion of the curriculum and two 14-

week final clinical education experiences. Sixteen third year students (response rate 27%)

volunteered to participate in interviews.

Methods

This is a grounded theory qualitative research study21 that was deemed not human subject

research from CMU Institutional Review Board. Interview questions were informed by the IBM

and designed to determine student insight into SPHM experiences in the clinic (Appendix). The

semi-structured interviews were completed individually and recorded digitally. Verbal consent

was received at the time of the interview. Digital audio files and subsequent transcriptions were

housed on a university-based server secured through the university’s Information Technology

Department. Interviews were transcribed with identifying data removed. Each transcription was

compared with audio files to ensure accuracy. Any discrepancies were discussed and corrected

upon consensus of the researchers. Based on agreed coding processes, each researcher

individually reviewed transcripts to find general consistent patterns of trends within the data. In

multiple discussions, researchers clarified major themes with supporting data. Member checking

was performed with 5 students who were in general agreement with the identified themes.

Results

Three major themes were identified from student interviews. Students report they could

1) identify when to apply SPHM principles and equipment during rehabilitation, 2) advocate for

5
SPHM principles when appropriate and 3) recognize barriers to integrating SPHM knowledge

into clinical practice.

Applying SPHM Knowledge in Clinical Practice

The students reported high confidence in their ability to identify situations where SPHM

equipment can be used and the type of the equipment that might be appropriate. One student

stated, “For pretty much all of my patients I decided [on what SPHM equipment to use] and I’d

consult with [my CI] if I really did have a question, but for the most part I was able to

differentiate that on my own and we went with it.” In addition, students discussed how the

equipment allowed them to challenge their clients in more functional ways without safety being

an issue, “I think that realistically, at the end of the day, it helped me to come up with safer ways

to try and progress patients. It’s helped them [patients] be more independent in their functional

goals.” For students who used SPHM equipment, most used equipment as a treatment option for

patients versus using it during an evaluation. When reflecting on their clinical experience, one

student recalled using the equipment during an evaluation, “The only time we used it during an

eval we had a gentleman who was a little over 600 pounds. So, we used two overhead systems

with him for the initial eval to get him standing at the edge of the bed. That was the only time we

used a lift for evaluation.”

Students also recognized when SPHM equipment was not appropriate. One student

working in an outpatient orthopedic setting said, “Most of the people that we worked with were

higher functioning. So, we didn’t really have the need for using the safe patient handling

equipment in that setting.” Another student explained her process of clinical reasoning while

considering the use of SPHM equipment, “If the patient were max or total assist, we

6
automatically would use the overhead lift unless the patient needed to practice independent

transfers without the equipment so they could function at home.”

Advocating Through Education

Students overwhelmingly reported they had many opportunities to advocate for SPHM

equipment to both clinical instructors (CI) and patients. One student discussed a situation where

their clinical instructor was not supportive of using SPH equipment, “They felt the equipment

would hinder [the patient] from being able to progress and so I had to defend my decision on

why I wanted to use the equipment, but I feel like I was able to effectively get the point across.”

This student continued to tell the interviewers that even though they were able to effectively get

the point across, because their clinical instructor was not comfortable using the equipment, the

student was not given the opportunity to incorporate it. Another student shared her experience

where the CI had never seen the piece of safe patient handling equipment before. The student

was able to explain the setup, how to use the equipment, and how it would benefit the patient to

their CI, “When the Rifton TRAM came into the office, my clinical instructor said ‘Oh what was

this? This is kinda cool looking.” So, I showed her how the harness worked, and I just talked

about how I used it for my patient’s and how it can offload the patient for weight bearing.”

Students mentioned having conversations about the role of equipment with patients prior

to using it in treatment. One student reflected on what they said to a client, “If we are in a safer

environment, we can push you farther but with this [equipment] we know that you are not going

to fall or have anything bad happen. So, we know that we can make you work harder for longer

and as you get more and more tired, we can up the support if you need it.”

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Identification of Barriers to Integrate SPHM Knowledge into Clinical Practice

Students identified barriers in attempts to use SPHM knowledge in the clinic. Several

students mentioned CI hesitancy or lack of knowledge about benefits or uses of equipment. One

student said, “I felt like [the patient] could have benefited from using the [equipment], but my CI

said that the set-up was extensive, and he [the patient] only had a week left and so she basically

told me that we can’t use it, even though I know [the patient] would have benefited from it.”

The students and clinical instructors were both restricted from using safe patient handling

equipment based on physician orders as well, “It wasn’t like my CI said don’t use it. It was the

physician who said don’t use it.”

Students felt culture of the facility limited use of SPH equipment as well. “If [the patient]

was ever going to be completely dependent we would have two people helping out and we could

even have more than that; often times it was me, a PT, and an OT. So, lots of co-treating was

happening and that was their way of keeping down the risk of just one person trying to max or

dependent transfer somebody.” Another student similarly reported, “The hospital is a little bit

different because you have your rehab team, you have your occupational therapist and your

speech therapist, and we had techs too so if it was like a max assist of two, you were able to call

on your staff to help you out.” Occasionally, the culture of the facility, including workplace

practices and the work environment, resulted in additional therapists providing manual assistance

for mobility instead of utilizing SPHM equipment.

Lack of access to the equipment was another barrier students reported limited their use of

the equipment. In certain settings, equipment was reserved for specific disciplines or hospital

floors instead of being available for the therapy staff. One student commented, “I had asked

about it while I was there, but they just reserved that [equipment] for the nurses or for the

8
neurological floor so nothing was available to me that I could have used.” Another student

experienced musculoskeletal injuries in the setting that had limited equipment in comparison to a

setting where the student had equipment readily available, “I definitely had more back pain in

my first rotation with basically no SPHM equipment compared to my second rotation where I

had barely any back pain and I used equipment daily.” Several students cited lack of quick

access as a barrier after reflecting on their final clinical experiences, specifically in the acute care

setting. One student reflected, “In the acute setting we were running around a lot to each room

and trying to get as many people done as we could possibly do. So, to take the time to go down a

few floors, go into the room, make sure it is charged, get all the things we need, bring it back up,

that already takes up their entire treatment time.”

Student Feedback on Curricular Process

Students provided insight into how the curriculum impacted their clinical experiences.

Several students recognized aspects of the program that facilitated their learning such as hands

on experience and being able to use the equipment. One student reported, “I feel like school was

really good about introducing us to all the equipment especially actually seeing it and using it in

person because I probably wouldn’t even know what the equipment was if I didn’t see it in

school.” Students also reported the case-by-case approach for clinical decision making as helpful

components of the program. “[The professor] forces you to come up with different exercises for

each piece of equipment based on patients with different severity of impairments. So, that helps

problem solve different cases.” Having both hands on experience and opportunities to clinically

reason through using SPHM equipment allowed students to feel confident advocating for it, “A

lot of the labs that we would do where we would have to come up with exercises and provide

rationale for it and do research on different articles that help support it really helped me be able

9
to advocate for it and allowed me to really believe in it and believe in my ability to use it and

defend my decision to use it.”

Students suggested more time could be dedicated to SPHM content for the acute care

setting. After finishing an acute care rotation, one student stated, “I would focus more on

anticipating when you think you’ll need more [assistance with mobility] based on clinical

judgement and chart review. I think that’s where the emphasis needs to be in acute care.”

Educating patients, families, and caregivers was another area that students felt could have been

emphasized in the didactic portion of their education, “If anything it would be educating the

family on the benefits or even the patient. Sometimes they’d question why are we in the harness

versus the parallel bars and we’d have to explain that.” Students also felt that more time should

be spent in examining uses of SPHM equipment for other settings than just acute care or

inpatient rehab settings. One student suggested, “I feel like a lot of what we talked about is more

specific neuro facilities or inpatient facilities, so talk about how it could be incorporated in a

regular outpatient setting.” Another student said this about SPHM content in the pediatric

courses, “They [SPHM equipment] are briefly discussed in our pediatrics course, but we don’t

get a ton of exposure to it, or any practice really, until you’re out in the clinic.”

Discussion

Our results indicate that the curriculum promoted skill acquisition and confidence that

allowed students to attempt integration of SPHM principles into final clinical education

experiences, especially in acute, subacute, and inpatient rehab settings. This curriculum applied

various, multi-faceted teaching methods as suggested by Perez et al and Perlow et al to

accommodate different learning styles.10,12 In addition, as Haines and Arnold recommended,5

10
opportunities are offered across the curriculum with equipment always available as part of the

clinical decision-making process.

According to the IBM, experiential attitude, knowledge and skills, saliency, environment

constraints and habit are factors that can drive behavior.18 This curricular design appeared to

positively influence these factors that addressed the value of utilizing SPHM in clinical practice

when appropriate. Students reported they felt confident to determine when SPHM equipment

could be beneficial, to select and use the equipment, and to advocate for equipment through

education. Contrary to other published studies,2,4 students in our study overall reported feeling

they had adequate exposure and knowledge regarding SPHM content while in the program,

especially those students in inpatient and subacute settings. Students in the acute care setting did

not use the equipment due to culture of the facility and lack of quick access to the equipment.

Students who had rotations in orthopedics or pediatrics recommend including additional

resources for use of SPHM equipment for higher level functioning patients.

Similar to Stevenson, students also identified clinical environmental constraints that

impacted their behavior to integrate this content during rotations.2 Students identified lack of CI

knowledge or reluctance, lack of access to equipment, and culture of facility as influences on

decision making and use. Although the curriculum positively influenced student behavior,

translating this content into practice was impaired in clinical settings that did not have

established practices in SPHM. The constraints of the clinical environment played a role in

student behavior in the clinic. One solution to bridge this practice gap would be for academic

institutions teaching SPHM content to work with clinical partners in the knowledge translation

process.

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Limitations/Future Research

The limitations of the study include a small sample size and lack of generalizability to

other DPT programs. Future research may address the impact of this curriculum to other DPT

programs. In addition, adopting a knowledge translation process with clinical partners to address

the practice gap and assessing change in behavior would be another area to explore.

Conclusion

The SPHM curriculum followed at this DPT program appeared to overall positively

influence student behavior to integrate SPHM knowledge into final clinical education

experiences. Clinical environmental constraints were identified as barriers by students to fully

utilize didactic knowledge while on final clinical education experiences. Enhancing academic

and clinical partnerships through the knowledge translation process was identified as one

solution to improving integration of SPHM principle into physical therapy practice.

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v.4 04/07/2021

References:

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http://www.apta.org/uploadedFiles/APTAorg/About_Us/Policies/HOD/Practice/

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http://www.capteonline.org/uploadedFiles/CAPTEorg/About_CAPTE/Resources/Accredi

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Appendix. Semi-Structured Interview Questions.