Improving Competency in Safe Patient Handling Through Online Learning Beyond the Classroom: A Longitudinal Study

Participants

All students enrolled in the undergraduate honors occupational therapy program at the University of Salford were included in this study. All student participants (N = 243; see Supplemental Appendix Table A.1, available online with this article at https://research.aota.org/ajot) had completed the tutor-led moving and handling practical training in Year 1. Students were excluded if their weight exceeded the safe working load of the equipment, had not attended the Year 1 training, or had an existing medical condition or injury that prevented them from carrying out moving and handling techniques.

Procedure

Student participants attended an individual 45-min competency evaluation session in which they demonstrated their practical skills and competency in carrying out four common moving and handling tasks: (1) assisted sit-to-stand (Task 1a), (2) repositioning in a chair using a one-way glide sheet (Task 1b), (3) inserting a pair of flat slide sheets to move someone up on the bed (Task 2), and (4) fitting a universal sling in sitting and hoisting from a chair (Task 3). These tasks had been demonstrated to students and practiced as part of their Year 1 mandatory 6-hr training.

Three practical skill stations containing the moving and handling equipment necessary for each practical task were set up in one clinical room at the University of Salford. Each station included one patient and one assessor to maintain consistency throughout the data collection, and screens were used to ensure privacy and avoid students observing each other. Students were allocated 15 min for each station (including scoring time and brief feedback). On completion of the task, each student moved on to the next practical skill station until all three stations were completed (Tasks 1a and 1b were combined in one practical station completed in 15 min). The total time required for all three tasks was 45 min.

Assessors

To ensure objective and robust assessment of the practical tasks, assessors were recruited from the occupational therapy teaching team to observe the students carrying out each task and score their performance. To minimize assessor variability, all assessors attended training and debriefing sessions at the university before data collection. The study aims were outlined to the assessors, and role play was used to apply the Competency Assessment Tool (CAT; see the Supplemental Appendix, available online) to each task, ensuring a standardized and objective approach and minimizing misinterpretation of the evaluation tool. To improve reliability and consistency of scoring, each assessor was assigned to only one practical station (i.e., one specific moving and handling task).

Patients

To evaluate skills effectively without introducing any bias or assistance from fellow students, patients were recruited to take part in each of the three tasks to be assessed. The volunteer patients involved in the study were older people who were not known to the students (ethical approval was received from the University of Salford ethics panel, No. HSCR14/123). Before data collection, these volunteer patients were briefed on their role in each task. Risk assessments approved through university ethics procedures were adhered to throughout data collection, and there was no incidence of injury to students or patients throughout the 3-yr study. The patients were instructed to be cooperative but not to assist or prompt the students in any way during the assessment.

Outcome Measure: Competency Assessment Tool

The CAT (see the Supplemental Appendix) was developed using standard guidelines from The Guide to the Handling of People (Smith, 2011), using activity analysis of each manual handling task linked to risk assessment and safe practice. The CAT was piloted in a previous study (Webb et al., 2016), is used in the assessor training, and is now available as the Salford Moving and Handling Competency Passport (Webb & Harrison, 2019). The CAT generates three different scores: (1) skill level (elements of task performed correctly), (2) number of errors (elements of tasks performed incorrectly), and (3) assessor’s perception of the student’s level of safety.

Data were collected with the CAT at three critical stages of the undergraduate program (see Supplemental Appendix): (1) beginning of Year 2 (September 2016), (2) beginning of Year 3 (September 2017), and (3) end of Year 3 (June 2018).

Safety Levels

After each task, the assessors were required to record whether they felt the student had displayed unsafe practice. Levels of safety at the final data collection point were significantly higher than those of Year 3 students who received traditional tutor-led training, with students who received the new competency approach scored at 100% safe on Task 1b (repositioning in chair using one-way glide sheet) and the more complex Task 3 (fitting a universal sling in sitting position to hoist from a chair). Students who received tutor-led training scored at 35% and 55% unsafe, respectively, on these tasks. Reductions in unsafe practice were also observed for Task 1a (assisted sit-to-stand), from 10% to 4%, and Task 2 (inserting flat slide sheets to move someone up on the bed), from 65% to 12%.

Increased Scores and Improved Skills

Results overall indicate continued positive outcomes, with students performing better on the more complex tasks than those who received traditional training with tutor-led sessions and annual updates. Statistically significant increases in scores were noted for Tasks 1b, 2, and 3 among Year 3 students, with a significant rise in competency before final placement. Results in the final data set also indicate a reduced range in scores, reflecting a more consistent level of competency in the cohort rather than a wider range that would suggest some students were performing very well and others were just barely achieving competency, as can be seen in some of the data from before September 2016 for students who received traditional training. This interactive approach is supported by Kolozsvari et al. (2011), who substantiated the merits of overtraining to achieve a level of competence beyond a basic pass mark, which ultimately enhances skill transfer in practice. The findings support Barnes’s (1998) practice learning approach of just-in-time training with the on-demand learning and fresh revision of contents accessed via the A1 online learning system closer to the time of use, which had a positive impact on comprehension and retention of information and helped to reduce errors.

Increased Safety Levels

Significant increases in student safety levels as a result of the competency approach were noted, in particular on Task 3. This task is the most complex of the tasks, with 55% of students who received the tutor-led approach being identified as unsafe. Despite the lack of additional practical training, at the endpoint measurement in June 2018, 100% of Year 3 students observed performing this task were considered safe. A similar trend was observed with the second most complex task, Task 2, on which unsafe practices were reduced from 65% to 12%. Access to the A1 online learning system using a strategic approach may have led students to focus on what they considered to be the more complex tasks, watching the videos at a time that suited them to boost their confidence during the competency assessment. Gallagher et al. (2014) noted that video-assisted instruction offers the advantage of students being able to pace their learning and, as a permanent resource, allows repetitive practice to aid in development and retention of psychomotor skills (Stefanidis et al., 2006). This study’s findings support those of Van Bruwaene et al. (2009) and Gallagher et al., demonstrating that access to the online system, combined with practice in the competency sessions, increases proficiency in skill development.

Increased Responsibility for Learning by Accessing the Online System

As previous advocates of hands-on skill development through practical tutor-led sessions, removal of this opportunity initially challenged our beliefs. We considered it to be a bold step in pedagogical delivery style. The changes held significant risk: What if students did not engage with the online system? How would they respond to taking away the practical sessions? What could this mean for patient safety? How would educators perceive the changes? Would students fail on placement?

What has become clear is that access to the A1 online learning system is a permanent and readily accessible resource (unlike the face-to-face tutor-led sessions that occurred only once a year). Students have taken more responsibility for their own learning and professional development, demonstrating more positive engagement in preparation for the classroom competency session. This proactive approach is an improvement on the previous approach in which students attended an update session, signed the register, and were deemed competent to practice for another year. Although initial feedback from tutors is lacking when engaging with the online system, the competency evaluation process and CAT feedback (Webb & Harrison, 2019) meets Van Bruwaene et al.’s (2009) recommendations to further motivate students to increase their practical skills. A study by Hills et al. (2012) explored changes in educational approaches with typical Generation Y, tech-savvy occupational therapy students, identifying a shift to multimedia education methods, including online learning, recorded lectures, and e-books. The Hills et al. study identified emerging technology for developing competence in practice skills and supported the use of simulation for practice placement preparation and debriefing as an experience to produce skills or responses (Merryman, 2010). The combination of the online system and the competency evaluation meets the recommendations of both of these studies and supports their positive findings.

This approach is not unique to occupational therapy or the student community, and similar strategies could be advantageous for a range of qualified professionals in the health care community, helping to bridge the gap between traditional training and often poor engagement with mandatory update sessions. A combination of access to the system to complete tests and quizzes, and to reflect on set problems or hot topics in a work environment, offers an alternative and often more engaging approach to continuing professional development. The A1 system allows for continual updates, responding to the common errors identified as part of the research and any changes in guidance from professional bodies or industries in the moving and handling community. Learner engagement is easily tracked and provides evidence of access to safe techniques, which could be useful if any critical incidents needing investigation occur in a range of health and social care facilities.

Reduced Classroom Update Sessions

Rather than ticking off a box for mandatory training attendance every 12 mo, the A1 system offers access to support whenever the learner needs it. This is particularly useful when teaching clinical skills relatively early in professional programs that may not be revisited until a later date, such as on a clinical placement (Gallagher et al., 2014). In this way, the online system and competency approach acts as an aide memoire to encourage safe application of skills and support clinical reasoning by providing an evidence-based, 24/7 multimedia risk assessment tool, encouraging active engagement and regular skills updates. Our results demonstrate that skills have improved along with levels of safety, with a marked reduction in student anxiety, particularly in the weeks before placement, when numerous requests for additional practical sessions did not occur, again saving staff resources in the delivery of ad hoc practical workshops to help alleviate students’ concerns.