A Discussion of Safety Training for Caregivers of People with Spinal Cord Impairment

by J.J. Juska and Alicia M. Alvero
Queens College and the Graduate Center of the City University of New York

According to an initial survey conducted at James A. Haley Veterans’ Hospital, an alarming number of wheelchair-bound patients with spinal cord impairment (SCI) require readmission to the hospital after discharge from acute care (Nelson et al. 2003). The authors examined patients who experienced fall-related fractures and found that 80% of patients who fell required inpatient stays of an average of 66 days. One of the leading activities resulting in falls was unsafe lifts done by families. Re-admittance to the hospital may burden patients and caregivers in areas of cost, time, and effort, and a number of other dimensions. Furthermore, hospital systems are already overtaxed in their physical therapy departments. It seems clear that re-admittance due to avoidable accidents strains patients, families, and hospital resources. Fortunately, there are a number of Organizational Behavior Management (OBM) techniques that can address patient safety in the home and ultimately decrease readmittance. These techniques include peer feedback, task analyses of safe lifts and transfers, and in-home caregiver training.

Of the 24 patients examined in the Nelson et al. (2003) study, most fall-related fractures in SCI patients were the result of home inaccessibility or inadequate support at home. Almost half of the fractures occurred during patient transfer, during which the families assisted the person in moving from point A to point B. For example, a transfer would be needed to move the patient from a wheelchair to a car, bed, toilet, or shower seat, or from the floor to the wheelchair following a fall. Performing a transfer requires the caregiver to support the weight of the patient. If performed unsafely, transfers can easily result in re-injury to the patient and injury to the caregiver. The studies discussed below indicate that use of OBM techniques has indications for improving family training.
Alavosius and Sulzer-Azaroff (1985) examined patient lifting techniques exhibited by nursing staff in a hospital setting. A safe lift is a vital component of accomplishing a safe transfer. The authors effectively trained nursing staff to perform safe lifts with patients using a task analysis, or step-by-step guide, for performing lifts. While safe lifts and transfers performed by nurses increase patient safety in the hospital and reduce on-the-job injury for nurses, the hospital staff that are responsible for training patient families in safety are the physical therapists. Despite this, our literature search did not reveal any research on family training packages designated to improve the safety of either the SCI patient or the family after hospital discharge.

A few studies with other populations have looked at potential benefits of introducing behavior management techniques to families. A recent study examined the effect of exercise and behavioral management in patients with Alzheimer disease (Teri et al. 2003). Participants were assigned to one of two groups: those who received routine medical care (RMC group) and those who received the Reducing Disability in Alzheimer Disease (RDAD) care package. The RDAD care package consisted of exercise, as well as a family behavior management training package, and was carried out in the home. The authors found that subjects in the RDAD group showed a trend toward fewer incidences of institutionalization due to behavioral disturbances. Although most measures taken in this study were standardized affective rating scales rather than behavioral outcomes, the results suggest caregiver training packages can help affect targeted dependent variables, such as mood and rate of institutionalization.

A study conducted by Gardner, Bird, Maguire, Carreiro, and Abenaim (2003) examined long-term outcomes of a behavioral treatment package on adolescents with acquired brain injury. This study sought to reduce episodes of aggression and property destruction while increasing self-help and daily living skills. Data were taken on targeted behaviors and showed reduction of challenging behaviors to zero rates. This study was done both in the participants’ homes and natural environments. The caregivers in the study performed the interventions. The home-based and caregiver intervention components of the study support the effectiveness of in-home interventions to reduce and/or improve targeted behaviors using behavioral management techniques.
In the case of spinal cord impaired patients, in-home behavior management could help prevent or reduce the incidence of caregiver and client injury. Components of the organizational behavior management model such as the use of feedback and use of data-based safety strategies could be implemented during standard family training sessions. These sessions usually occur toward the end of the physical therapy sessions. In a typical intervention, therapists train families to perform lifts and transfers until the families can execute these skills to the therapist’s satisfaction.

There are several glaring problems with the model described above. First of all, the staff responsible for training the families may themselves be executing lifts and transfers in an unsafe manner. Secondly, criteria for safe transfers are not typically standardized. Furthermore, no data are taken to ensure that caregivers are actually performing safe transfers, or to ensure reliability among therapists that the caregiver can adequately execute the transfer.

There are several steps that might reduce the reoccurrence of injury for people with SCI and their caregivers. Before families are introduced to the skill set, the physical therapists need to be evaluated and, if necessary, receive further training to criteria for mastery of safe lifts and transfers. In the study by Alavosius and Sulzer-Azaroff (1985), the steps of two types of transfers were described in task analyses that were used to evaluate and train therapists. In a follow-up 1986 study, Alavosius and Sulzer-Azaroff evaluated the effects of performance feedback on the safety of client lifting and transfer. The latter study was conducted in a state residential school for the mentally retarded. Direct care staff members were given written and verbal performance feedback contingent on their execution of lifts and transfers. Results demonstrated an improvement to near-perfect rates of safe performance. A similar or identical procedure could be implemented in physical therapy settings to improve safe lifting techniques of physical therapists. Furthermore, a study on feedback given by peers may lead to a feedback model that is feasible to implement in busy hospital settings where supervisors may not be have time to give adequate or effective feedback.

Once therapists can perform safe lifts and transfers, their evaluation skills should be frequently assessed. The ability to lift safely and evaluate another person’s safety may differ, and it is crucial to have therapists accurately score safety performance. In a physical therapy setting, the therapist’s extensive knowledge of the SCI patient’s strengths and weaknesses may affect safety scoring. Furthermore, a therapist’s feelings towards the family of the patient may affect both the perception of their skills and the amount of time the therapist is willing to spend with the family. Reliability data, or data directly sampled by two or more therapists at the time of family training, would help reduce individual therapist evaluation error.

Once it has been established that therapists are collecting reliable data, therapist training techniques can be examined. Therapists can use data-based and behavior-based safety strategies such as recording performance on task analyses and giving feedback for family safety performance management. Collecting data during training sessions would allow therapists to give accurate feedback and train families to execute safe lifts and transfers until mastery criteria has been reached.
Finally, an intervention without follow-up data of skill maintenance is comparable to giving childbirth and receiving no post-partum care. Once families and SCI patients return to the home, lift and transfer safety may become less important in an environment with competing stressors such as modifying the home for the patient, readjusting family schedules to accommodate care for the person, helping children in the house understand the household changes, and balancing new financial stressors. Hospitals might implement an outreach safety maintenance program comprised of physical therapists whose goal is to maintain safe performance in the home. Families could also be responsible for the maintenance of safety behavior and report back to the physical therapists. Safety maintenance therapists could be trained in behavioral techniques that might assist the family with maintaining previously mastered safety skills. Safety maintenance therapists might implement visual supports and prompts, as well as remove any household obstacles that might contribute to re-injury. As indicated by the studies discussed above, behavioral management in the home can lead to positive outcomes.

Re-injury and re-admittance to hospital and rehabilitation programs strains the resources of families, hospitals, and hospital staff. Use of organizational behavior management techniques in both the rehabilitation settings and home settings may contribute to a lowered rate of caregiver and SCI patient injury. Despite these potential benefits, research in this area is nearly nonexistent. Perhaps it is time to change this trend.

References

Alavosius, M.P., & Sulzer-Azaroff, B. (1985). An on-the-job method to evaluate patient lifting techniques. Applied Ergonomics, 16, 307-311.

Alavosius, M.P., & Sulzer-Azaroff, B. (1986). The effects of performance feedback on the safety of client lifting and transfer. Journal of Applied Behavior Analysis, 19, 261-267.

Gardner, R.M., Bird, F.L., Maguire, H., Carreiro, R., & Abenaim, N. (2003). Intensive positive behavior supports for adolescents with acquired brain injury: Long-term outcomes in community settings. Journal of Head Trauma Rehabilitation, 18(1), 52-74.

Nelson, A., Ahmed, S., Harrow, J., Fitzgerald, S., Sanchez-Anguiano, A., & Gavin-Dreschnack, D. (2003). Fall-related fractures in persons with spinal cord impairment: A descriptive analysis. SCI Nursing, 20(1), 30-37.

Teri, L., Gibbons, L.E., McCurry, S.M., Logsdon, R.G., Buchner, D.M., Barlow, W.E., Kukull, W.A., LaCroix, A.Z., McCormick, W., & Larson, E.B. (2003). Exercise plus behavioral management in patients with Alzheimer disease: A randomized controlled trial. Journal of the American Medical Association, 15, 2015-2022.