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Validity and reliability of the HEMPA method for patient handling assessment

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DOI: 10.1016/j.apergo.2017.06.018

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 Applied Ergonomics 65 (2017) 209e222

Contents lists available at ScienceDirect

Applied Ergonomics
journal homepage: www.elsevier.com/locate/apergo

Review article

Validity and reliability of the HEMPA method for patient handling

assessment
A. Villarroya a, *, P. Arezes b, S. Díaz de Freijo c, F. Fraga c
a
Lucus Augusti Hospital, Servizo Galego de Saúde, Rúa Dr. Ulises Romero, nº 1, 27004 Lugo, Spain
b ~es, Portugal
Research Centers for Industrial and Technology Management & Algoritmi, School of Engineering, University of Minho, 4800-058 Guimara
c
Department of Applied Physics, Faculty of Science, University of Santiago de Compostela, Lugo, Spain

a r t i c l e i n f o a b s t r a c t

Article history: Specific methods currently exist to assess occupational hazards resulting from patient handling in the
Received 12 March 2016 healthcare sector, according to ISO/TR 12296. They are all similar in nature, but with a different analysis
Received in revised form perspective; for that reason a comparison of the most relevant methods was performed in a previous
3 May 2017
research. As a result, a basis of a new tool that integrates the complementary aspects of those methods
Accepted 24 June 2017
was proposed. To verify the validity and reliability of that method, a study within a hospital setting was
carried out in five medical and surgical units of a public health institution. Based on the obtained results,
the analysed method (called HEMPA) proved to be valid and reliable. Also, this method reflects a positive
Keywords:
Risk assessment
correlation between risk and damage and correctly quantifies risks regarding patient's dependence.
Patient handling © 2017 Elsevier Ltd. All rights reserved.
Hospitals
Ergonomics
HEMPA

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 210
2. Materials and methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 210
2.1. 2.1 HEMPA items . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 210
2.2. Items scoring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211
3. Dependency level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211
3.1. Environmental conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211
4. Workspaces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211
5. Minor aids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211
6. Major aids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 212
7. Transfer execution and postural analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 213
8. Handling outcome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 213
8.1. Work organization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 213
9. Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 213
10. Risk perception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 213
10.1. Risk levels obtained by the final score . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 213
10.2. Field work . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 213
11. Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 214
11.1. Validation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 214
11.2. Validity of formal and content aspects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 214
11.3. Construct validity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215

* Corresponding author.
E-mail addresses: alberto.villarroya.lopez@sergas.es (A. Villarroya), parezes@
dps.uminho.pt (P. Arezes), santifreijo@mundo-r.com (S. Díaz de Freijo), Francisco.
Fraga@usc.es (F. Fraga).

http://dx.doi.org/10.1016/j.apergo.2017.06.018
0003-6870/© 2017 Elsevier Ltd. All rights reserved.
210 A. Villarroya et al. / Applied Ergonomics 65 (2017) 209e222

11.3.1. Association between theoretical risk and the results of the method . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215
11.3.2. Association between the method results and accident rate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215
11.4. Reliability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 216
11.4.1. External reliability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 216
11.4.2. Inter-observer reliability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217
11.4.3. Reliability of internal consistency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 218
12. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 218
checklist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 218
Patient handling assessment method “HEMPA” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 218
Final risk level of the unit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221

1. Introduction method (proposed by Fray and Hignett, 2013) aims to evaluate both
complex and multifactorial interventions during patient handling.
It is a frequently reported fact in the scientific literature that Other tools combine several strategies integrated into a single
patient handling is one of the main risk factors among caregivers generic program, to improve worker's occupational health (Hignett
(Engkvist et al., 1998; Goldman et al., 2000), particularly in terms of and Fray, 2010). Also it has been proposed a method to compare all
back pain (Hoogendoorn, 2002; Smedley and Egger, 1995) and patient handling tasks, based on the examination of twelve vari-
musculoskeletal disorders development (Larese and Fiorito, 1994; ables, setting a single indicator to evaluate all the interventions
Leigthon and Reilly, 1995; Ando et al., 2000). Caregivers are (Fray and Hignett, 2010).
exposed to various risk factors, such as lifting and transferring Keeping that orientation, a study comparing five of the most
patients, pushing and pulling heavy equipment or working in relevant assessment methods of patient handling -MAPO, DINO,
awkward postures (National Research Council and Institute of PTAI, Care Thermometer and Dortmund Approach, all of them
Medicine, 2001). Musculoskeletal disorders are therefore of included in ISO/TR 12296:2012 standard-was developed (Villarroya
particular relevance, as workers who experience pain or fatigue are et al., 2016). With this purpose, the most valued items were inte-
more likely to suffer accidents. In fact, some workers who suffer grated into a single method called HEMPA (“Herramienta de eval-
disabling injuries have abandoned the profession (Stubbs et al., uacio n de movilizacio n de pacientes”, or “Patient handling
1986). Moreover, workplaces with a high incidence of these risks assessment tool”) to obtain an overall quantitative assessment.
support high losses, with increased costs and staff turnover (OSHA, HEMPA intends to be a comprehensive method, regardless the
2009). Regarding musculoskeletal disorders due to biomechanical weaknesses or limitations of the previously compared methods,
overload, it was found that there is prevalence of back pain among which also pursue the same purpose, that is, to evaluate patient
nurses, particularly in the lumbar region, mainly because of the handling risk, although they follow different pathways. This tool
great variability of patient handling, the nature of liftings and the aims to provide a quantitative final result to determine whether the
lack of training about the correct execution of movements (Bordini risk of suffering musculoskeletal disorders during patients transfer
et al., 1999). In addition, patient handling has been increasingly is acceptable, moderate or unacceptable for the caregiver, regarding
recognized as a high risk activity, so the task could be redesigned to the patient's degree of dependence. Therefore, the aim of the cur-
reduce risk exposure, implementing practical handling programs to rent study is to establish the validity and reliability of the HEMPA
improve the patient safety (De Castro et al., 2006). method to assess patient handling risks, similarly to other previ-
Another study also suggests that injuries severity can be ously published studies (Radovanovic and Alexandre, 2004; Battevi
reduced substantially with a proper ergonomic intervention to et al., 1999, 2006). This paper also includes a brief discussion of the
reduce the physical stress and the risk of injury of caregivers (Garag considered items, the way scores are assigned as well as the
and Owen, 1994). quantification of the resulting risk levels.
Regarding the above, it is known that there have been major
advances studying working conditions, aiming at accurately assess 2. Materials and methods
risks. Among these advances, there are certain methods to evaluate
the patient handling technique (Kjellberg et al., 2000) or specific 2.1. 2.1 HEMPA items
methods as MAPO, DINO, Dortmund Approach, Care Thermo-
mether or PTAI that proved to be valid, as reported in previous HEMPA is an assessment tool based in observation of work-
studies (Battevi et al., 2006; Johnsson et al., 2004; Jager et al., 2010; places where patient handling takes place regularly. The method
Steer and Knibbe, 2008; Karhula et al., 2009). Additionally, it has compiles the items that were considered to be relevant in the
been shown that multifactorial interventions are most appropriate previously mentioned comparison (Villarroya et al., 2016). These
for reducing musculoskeletal injury rates (De Troyer, 2015). In this items are major components of a typical healthcare scenario,
sense, the European Panel on Patient Handling Ergonomics (EPPHE) mostly cited in ISO/TR 12296, and are taken from the valuation
in its international technical report recommended a comprehen- criteria adopted by the different methods analysed:
sive strategy, based on risk analysis associated with patient
handling and taking into account all factors that could affect that a) Dependency level.
task in the most complete way. b) Environmental conditions.
For that reason, it seems clear that prevention of musculoskel- c) Workspaces.
etal disorders resulting from patient handling requires proper d) Minor aids.
assessment tools to provide the most balanced approach possible, e) Major aids.
according to a group of variables that influence this handling. Thus, f) Transfer execution and postural analysis.
due to the lack of a comprehensive measurement tool, the TROPHI g) Handling outcome.
 A. Villarroya et al. / Applied Ergonomics 65 (2017) 209e222 211

h) Work organization. a co-operating patient may result in a low hazard, while handling a
i) Training. non co-operating patient may produce a much higher hazard, as
j) Risk perception. other publications denote (Knibbe and Waaijer, 2008).
To obtain the final score of the item, sub-total A and sub-total B
are added and then divided by 2. Regardless the number of patients,
each type of patient is multiplied by the corresponding correction
2.2. Items scoring
factors that appear in Table 3 and then divided by the number of
patients analysed; that is, a score is assigned for the combination of
The score for each item is based on the frequency with which
the different levels of mobility and collaboration.
each item was repeated in the comparative study among the five
reference methods, namely MAPO, DINO, PTAI, Care Thermometer
and Dortmund Approach. 3.1. Environmental conditions
The reason underlying the selection of those methods was the
different range of aspects valued by each of them. This allows to This item, based in other similar studies (Zimring and Ulrich,
cover a wide range of study variables, including the work organi- 2004) has a maximum score of 1 point, distributed among the
zation (MAPO), patient handling technique (DINO), the physical sub-items presented in Table 4, whose scores are obtained ac-
load caused by transferring patients (PTAI), residents care (Care cording to its suitability, as shown in the same table.
Thermometer) or the lumbar load supported by caregivers (Dort- The scoring of each sub-item is done through some technical
mund Approach), among other factors. Each of these tools had, measures by an ergonomics professional, checking if the mea-
therefore, valuable specific and complementary features, signifi- surements obtained suite the levels of Table 4, established in the
cant of its inclusion. Thereafter, ten items were choosed to facilitate Royal Decree 486/1997, where the minimum health and safety re-
the comparison between methods. This selection was based on the quirements are set for workplaces (BOE nº 97, 04.23.1997). The final
similarity of content that usually have specific risk assessment score of the item would be an average punctuation, obtained by
methods of patient handling, also picked in a similar manner in adding the total score achieved divided by the total number of
other related studies (Tamminen-Peter et al., 2009). Furthermore, it rooms analysed.
should be noted that the selection of those items was based on
relevant publications on the subject (Villarroya et al., 2016). 4. Workspaces
The scoring criterion adopted was designed to give a specific
weight to each item, according to the frequency in which a given This item, studied in related literature (Knibbe and Knibbe,
aspect is observed in all methods. The maximum score of the items, 1996; Runy, 2004; Victorian WorkCover Authority, 2004), has a
obtained from the evaluation criteria contained in each method, maximum score of 5 points and considers bathroom access, the
was assigned the higher was the frequency. toilet characteristics, the possibility of regulation of beds to handle
For its part, the scoring criterion adopted for each HEMPA item is patients at an appropriate height and the space room to perform
explained as follows: handling in a safe way. Score is assigned based on suitability, and it
is distributed among several sub-items, as shown in Table 5.
3. Dependency level Most of the characteristics described depend on the degree of
compliance with regulations governing architectural barriers.
The value of this item has a maximum score of 3 points, ob- These distances should be measured to ensure that there is suffi-
tained by combining patient mobility and patient dependence. On cient space to use various patient-handling devices. The final score
one hand, patient mobility (Sub-total A) is divided in five levels, of the item would be an average punctuation, obtained by adding
mainly based on the “Mobility Gallery” of Care Thermometer the total score achieved divided by the total number of rooms
method (Steer et al., 2008), each one with an assigned score as analysed.
defined in Table 1:
On the other hand, regarding the patients collaboration level 5. Minor aids
(Sub-total B), a score is assigned according to the handling type, as
shown in Table 2: The biomechanical effectiveness of minor aids is proven, as
Collaboration levels are described in “ISO/TR 12296: 2012”. This considered in numerous studies (Elford et al., 2000; Yassi et al.,
standard state that the patients mobility level should be assessed 2001; Jager et al., 2013). In that sense, this item values the avail-
considering that fully co-operating patients do not need any help in able equipment to perform patients’ lifting, ambulation or trans-
handling, partially co-operating patients need help during ferring, as well as the existence of other minor aids (transfers,
handling, and non co-operating patients need to be fully lifted sliding sheets, etc).
during handling. In this sense ISO/TR 12296 indicates that handling The item has a maximum score of 5 points. 1.25 points are

Table 1
Mobility levels and score.

Mobility level Handling type Score

Level A: independent patients which dress and clean up by Safe handling: patients never depend on the caregiver. 3 points.
themselves.
Level B: Patients able to support themselves while standing, Virtually safe handling: patients rarely depend on the caregiver. 2,40 points.
using a walker or a similar aid.
Level C: Patients keep standing partially, but often require a Partially safe handling: patients depend on the caregiver in many situations. 1,80 points.
wheelchair.
Level D: Patients unable to stand on their legs. Practically unsafe handling: patients dependent on the caregiver most of the time. 1,20 points.
Level E: Patients completely bedridden. Unsafe handling: patients always depend on the caregiver. 0,60 points.
212 A. Villarroya et al. / Applied Ergonomics 65 (2017) 209e222

Table 2
Collaboration levels and associated scores.

Patients Handling type Score

collaboration level

Level 1: Fully co- Safe handling, if patients are collaborators (autonomous patients that collaborate with caregivers during handling). 3 points.
operating
Level 2: Partially Partially safe handling, if patients are partially collaborators (patients that have a residual motor capacity and only rise partially). 2 points.
co-operating
Level 3: Non co- Unsafe handling, if patients do not collaborate at all (patients that cannot use upper and lower extremities, and therefore must 1 point.
operating be fully raised in transfer operations).

Table 3
Combined scores for the different levels of mobility and collaboration.

Level A Level B Level C Level D Level E

Level 1 3 2,70 2,40 2,10 1,80

Level 2 2,50 2,20 1,90 1,60 1,30
Level 3 2 1,70 1,40 1,10 0,80

Table 4
Score assigned for environmental conditions.

Sub-item Adequacy Score

Temperature The proper temperature where work is carried out is set to be between 14
C 0.25 points if appropriate, 0 points if inappropriate.
and 25
C.
Humidity The appropriate relative humidity is set to be between 30 and 70%. 0.25 points if appropriate, 0 points if inappropriate.
Lighting The minimum required level for an adequate lighting is 500 Lux, since visual 0.25 points if appropriate, 0 points if inappropriate.
demands for handling patients are considered to be high.
Acoustic discomfort The equivalent continuous pressure sound level is 40 dB(A) for the period 0.25 points if appropriate, 0 points if inappropriate.
between 7:00 and 23:00 h, and 30 dB(A) for the period between 23:00 and 7:00.

Table 5
Workspaces scores assignment based on their suitability.

Sub-item Adequacy Score

Bathroom Bathroom access without obstacles 0.625 points if appropriate, 0 points if inappropriate.
Door width of at least 85 cm, and adequate space for proper handling of mechanical aids. 0.625 points if appropriate, 0 points if inappropriate.
WC Height toilet cup of at least 50 cm high and presence of lateral support bar, next to the toilet. 0.625 points if appropriate, 0 points if inappropriate.
Adequate working space for handling a wheelchair. 0.625 points if appropriate, 0 points if inappropriate.
Adjustable beds Possibility of mechanical regulation of beds, in both height and tilt of the headboard. 1.25 points if appropriate, 0 points if inappropriate.
Rooms Space between beds of at least 90 cms. 0.625 points if appropriate, 0 points if inappropriate.
Free space of at least 120 cm from bed foot to the wall. 0.625 points if appropriate, 0 points if inappropriate.

assigned for each type of existing aid among those listed in the patients walking. The final score of the item would be an average
checklist (see Annex point 4, “Minor aids”). It should be noted that punctuation, obtained by adding the total score achieved divided
each aid only rates if it previously meets all the requirements of by the total number of aids analysed.
table “Mechanical aids-Previous Requirements” (see Annex point 4,
“Minor aids”), namely, that the aids are available on the unit and in
a sufficient quantity, are adequate for the specific handling, and are 6. Major aids
in suitable maintenance conditions, among other aspects. To clas-
sify minor transfer aids, it was used the “ISO 9999: 2011. Assistive This item has a maximum score of 5 points, and values the
products for persons with disability. Classification and terminol- available equipment for aiding the patient's lifting or transferring,
ogy”, as follows: (mechanical lifting devices, etc.) similarly to other analysis (Knibbe
and Knibbe, 1996). 1.25 points are assigned for each type of existing
* Assistive products for transfer and turning: aid of those listed in the checklist (see Annex point 5 “Major aids”).
- Sliding sheet. It should be noted that each aid only rates if previously meets all
- Transfer platform. the requirements of table “Mechanical aids-Previous Re-
- Rotating disk or turntable. quirements” (see Annex point 5 “Major aids”), namely, that the aids
* Assistive products for walking: are available on the unit, in a sufficient number, are adequate for
- Walker or standing hoist. the specific handling, and are in suitable maintenance conditions,
among other aspects.
In this last case, it was considered a walker as an aid for the To classify the major aids it has been used the standard “ISO
caregiver, because although it is mainly used by the patient, it re- 9999: 2011. Assistive products for persons with disability. Classifi-
duces the load supported by the caregiver when he accompanies cation and terminology”, which resulted in the following
classification:
 A. Villarroya et al. / Applied Ergonomics 65 (2017) 209e222 213

* Assistive products for lifting: also valued in related literature (Kjellberg et al., 1998). The score is
- Patient lift. assigned as indicated in Table 7:
* Assistive products for personal mobility: The final score of the item would be an average punctuation,
- Wheelchair. obtained by adding the total score achieved divided by the total
- Height-adjustable bed. number of wards analysed.
- Height-adjustable stretcher.

The final score of the item would be an average punctuation, 9. Training

obtained by adding the total score achieved divided by the total
number of aids analysed. The item values a key aspect of manual patient handling
(Martimo et al., 2008; Schibye et al., 2003), and has a maximum
7. Transfer execution and postural analysis score of 2 points and assess specific training in manual patient
handling, as reflected in Table 8.
This item has a maximum score of 4 points and analyses the The final score of the item would be an average punctuation,
main manual patient handling transfers, as established by several obtained by adding the total score achieved divided by the total
authors (Jager et al., 2010; Marras et al., 1999). For each task per- number of wards analysed.
formed in an acceptable way, 0.40 points are assigned, considering
“acceptable” the task executed without adopting awkward pos-
10. Risk perception
tures; otherwise no points are assigned. The transfers covered are:

This item, based on psychosocial factors studied by other au-

- Lift a patient into a seated position.
thors (Warming et al., 2009) has a maximum score of 1 point and it
- Move a patient towards the bed's head.
takes into account, by asking caregivers, if there is any physical or
- Move the patient to one side of the bed.
mental load, as shown in Table 9. It should be noted that it can be
- Raise patient's legs.
made as many queries as workers wish to participate, dividing the
- Incline the bed's head.
total score obtained by the number of participants.
- Shove a bedpan.
- Place minor aids.
- Transfer the patient from bed to bed. 10.1. Risk levels obtained by the final score
- Place from bed into a chair.
- Raise the patient from sitting to standing position. To obtain the final score and the corresponding risk level of each
unit or service assessed, the partial scores of all items are summed,
The final score of the item would be an average punctuation, up to a maximum score of 30 points. This score is subdivided into
obtained by adding the total score achieved divided by the total three risk levels (Table 10), based on the standard UNE-EN 614e1
number of patients analysed. “Guidelines for the use of 3-zone rating system”, Annex A.
The risk levels (acceptable, medium and unacceptable) were
8. Handling outcome determined after discussion of the authors of this paper during
content validity evaluation, just as it was done in other tools
This item has a maximum score of 2 points. For meeting each of (Radovanovic and Alexandre, 2004). Also, it was previously checked
the situations reflected in Table 6, a maximum of 0.50 points are if the midpoint of the method score was correctly calibrated, as
assigned to the four sub-items: reflected in paragraph 3.3.2. of this paper.
The aim is to see if transfers are executed correctly, as also
determined by other authors (Kjellberg et al., 2004; NHS Estates,
1997) That is, if the caregiver does not have the need to do the 10.2. Field work
tasks again, or that the caregiver does not suffer physical overload
by making transfers quickly or by a sudden movement of the pa- To evaluate the reliability and validity of the HEMPA method a
tient agitated by fear, or because the mechanical aids must be used study was carried out in various hospital wards at the public hos-
subsequent by an incorrect patient positioning. The final score of pital Lucus Augusti (Galicia, Spain). Hospital supervisory staff had
the item would be an average punctuation, obtained by adding the been informed and gave their consent to this research. The main
total score achieved divided by the total number of patients tasks observed during the study were the patient's hygiene,
analysed. transfers and all the in-bed postural changes epreviously checking
the list of categories included in HEMPA item “Transfer execution
8.1. Work organization and postural analysis”e, both organizational and work environ-
ment aspects (rooms conditions, mechanical aids), as well as the
This item has a maximum score of 4 points, and considers the ergonomic appropriateness of those tasks that represent more
work pace and breaks, the patients’ ratio per caregiver, the night- problems regarding work accidents by overexertion, using the
time service and the peer support for handling patients, elements checklist designed for this purpose (see Annex).

Table 6
Score assigned according to the handling outcome.

Sub-item Score

The transfer technique used causes no pain to the patient. 0.5 points if it occurs, 0 points if it does not occurs.
The transfer technique causes no fear or uncertainty to the patient. 0.5 points if it occurs, 0 points if it does not occurs.
Transfer is not done quickly or rushing. 0.5 points if it occurs, 0 points if it does not occurs.
At the end of the transfer the patient is in an appropriate posture 0.5 points if it occurs, 0 points if it does not occurs.
214 A. Villarroya et al. / Applied Ergonomics 65 (2017) 209e222

Table 7
Score assigned to the work organization.

Sub-item Score

Ratio patient/caregiver. 0.5 points if the number of patients per worker is appropriate, depending on the ratio established by the care plan according
to the patient's severity.
Nocturnity. 0.25 points if there is no night work.
0.25 points if, when working at night, there is a minimum rest period of one day until the caregiver comes back to work.
Peer support. 0.5 points if usually there is peer support handling dependent patients.
Workpace and breaks. 0.25 points if patient handling is done without time pressures.
0.25 points if periodic breaks are set to rest.

Table 8
Score assigned for specific training in manual patient handling.

Sub-item Score

Information about risks related to manual patient handling in the workplace. 0.5 points if is fulfilled, 0 points otherwise.
Theoretical and practical training in manual patient handling imparted to at least 75% of the employees of the unit. 0.5 points if is fulfilled, 0 points otherwise.
Practical training in the use of mechanical aids imparted in the last two years. 0.5 points if is fulfilled, 0 points otherwise.
Verification of the training validity, regarding its effectiveness in reducing accidents. 0.5 points if is fulfilled, 0 points otherwise.

Table 9
Risk perception score.

Sub-item Score

a. Do you think that the working postures adopted during patient 0.25 points if the answer is positive, 0 points if the answer is negative.
handling pose no damage to your health?
b. Are patients transfers planned in advance? 0.25 points if the answer is positive, 0 points if the answer is negative.
c. In your opinion, the patients handled are light or moderately heavy? 0.25 points if the answer is positive, 0 points if the answer is negative.
d. Patients transfers are not continuous or occur spaced along the work 0.25 points if the answer is positive, 0 points if the answer is negative.
shift?

Table 10
Final score range and corresponding risk levels.

Risk level Score range Meaning

Green From 20.01 to 30 points. The risk of musculoskeletal disorders suffered by caregivers during patient mobilization is acceptable.
Yellow From 10.01 to 20 points. The risk of musculoskeletal disorders suffered by caregivers during patient mobilization is moderate.
Red 0.8 to 10 points. The risk of musculoskeletal disorders suffered by caregivers during patient mobilization is unacceptable.

11. Results study by six experts in healthcare ergonomics, all belonging to the
“Group of Hospitals” that cooperates with the Spanish National
11.1. Validation Institute of Safety and Health at Work (INSHT). Delphi is a method
which relies on a panel of experts who are asked for their opinion
In order to validate the HEMPA method, 10 of the 16 hospitali- on successive rounds in order to achieve a consensus (Vernon,
zation units were studied with that tool, divided into 5 medical 2009).
units and 5 surgical units. It should be noted that the medical units Various formal and content aspects were checked through a
are used for medical care of patients with different diagnostic or questionnaire established for this purpose. On one side, formal
therapeutic procedures, while the surgical units are designed to aspects are those which refer to the structure of the tool, especially
accommodate both patients who have suffered a surgical inter- regarding its understandability and wording. Questions posed to
vention and patients with diseases associated with specialties that experts about formal aspects were “Wording of the item is properly
require surgical treatment. Within the medical units, it were understood”, “Options offered by the item are properly under-
considered the specialisations of Paediatrics, Obstetrics, Psychiatry, stood” and “Item responses are the most appropriate”. On the other
Gastroenterology and Neurology, while in surgical units it were hand, content aspects are those which refer to the elements that
considered Traumatology, General Surgery, Internal Medicine compose the method, in particular related with the items suit-
(Surgery), Ophthalmology/Urology and Dermatology/Traumatol- ability. Questions posed to experts about content aspects were “The
ogy. In short, in the field work were included 62.50% of the total item is well oriented to the purpose of the method”, “The item
inpatient units, 52.30% of active beds and 62.56% of the hospital belongs to the correct section”, “The item contains the information
workers (134 nurses, 110 nursing assistants and 10 orderlies from a necessary to assess the risk”, “The score given to each item is
total of 406 workers). appropriate”, and “The assessment is simple and effective”. In both
formal and content aspects, the group of experts valued with a
11.2. Validity of formal and content aspects score from 0 to 10 the importance of each HEMPA item. When
testing the validity using Delphi, Annex A (HEMPA checklist) was
The HEMPA method was previously evaluated through a Delphi provided to the experts, as well as the details explained in section
 A. Villarroya et al. / Applied Ergonomics 65 (2017) 209e222 215

Table 11
Experts rating about the formal aspects of the HEMPA method.

Item First Round Second Round

Min Max Average Standard Deviation Min Max Average Standard Deviation

1.Dependency level 6 10 7,94 1,43 8 10 9,16 0,93

2.Environmental conditions 7,33 10 8,97 0,97 8,33 10 9,24 0,68
3. Workspaces 7 9,66 8,77 1,04 8,33 9,66 9,10 0,50
4. Minor aids 4 9,66 7,83 2,30 7 9,66 8,55 1,12
5. Major aids 5,33 9666 8,16 1,95 7 9,66 8,71 1,10
6. Transfer execution and postural analysis 6 10 9,33 1,63 8 10 9,66 0,81
7. Handling outcome 5,33 9 7,72 1,43 8 9 8,38 0,44
8. Work organization 6,66 10 8,88 1,72 8 10 9,38 0,95
9. Training 8 10 9,38 0,80 8,33 10 9,44 0,68
10. Risk perception 7 10 8,88 1,32 7,66 10 8,99 1,15

Table 12
Experts rating about the content aspects of the HEMPA method.

Item First Round Second Round

Min Max Average Standard Deviation Min Max Average Standard Deviation

1.Dependency level 8,4 10 9,2 0,53 8,4 10 9,53 0,62

2. Environmental conditions 7 10 8,56 1,57 7 10 8,96 1,26
3. Workspaces 7,6 10 9,3 1,1 7,8 10 9,33 0,87
4. Minor aids 6,2 10 8,73 1,65 8 10 9,23 0,89
5. Major aids 6,4 10 8,73 1,58 8 10 9,23 0,88
6. Transfer execution and postural analysis 7,2 10 9,46 1,12 7,8 10 9,56 0,88
7. Handling outcome 6,6 10 9,10 1,46 8 10 9,40 0,93
8. Work organization 7,0 10 8,63 1,20 7,8 10 8,96 0,79
9. Training 8,0 10 9,43 0,89 8,0 10 9,56 0,80
10. Risk perception 7,2 10 9,10 1,05 8,0 10 9,33 0,74

2.2 of this paper. It was accepted as valid for each of the items an sample, a parametric test and a nonparametric test for difference in
average score greater or equal than 7.5 points out of 10, both for means were used, namely the T Student test and the Mann-
formal (Table 11) and content aspects (Table 12). This result was Whitney test, the latter used in a similar study (Radovanovic and
reached after two rounds. Once the first round was made, HEMPA Alexandre, 2004).
was modified following the suggestions of the experts. A second Data obtained is reflected on the following statistical descriptive
round with Delphi was made trying to improve the scores obtained study (Table 13).
in the first round, in order to reach a consensus. In both tests it was found that there is a significant difference,
Finally, experts agreed to consider the method as an appropriate which means that HEMPA identifies that there is higher risk
tool to assess the risk of handling patients, both in the formal as- (average 13,98) the greater the patient dependence is (surgical
pects and content aspects. In addition, the method has been valued units), and there is lower risk (average 18,99) the lower the patient
as being comprehensive, as it evaluates a wide range of risk factors dependence is (medical units). It should be noted, as it was already
in the healthcare context. mentioned, that HEMPA gives lower numerical scores to high risk
situations.

11.3. Construct validity

11.3.2. Association between the method results and accident rate
11.3.1. Association between theoretical risk and the results of the To check whether HEMPA is capable of correctly predict the
method units with higher risk, according to the previously registered acci-
Assuming that the risk level of patient handling -based on his dents, data was collected directly from the Occupational Health
level of mobility and collaboration-tend to be higher when the Unit records of the Lucus Augusti Hospital, that contains accidents
degree of dependence is also higher, a study was conducted to due to musculoskeletal disorders compiled from 2011 to 2014.
compare the results obtained with HEMPA in the medical (theo- Musculoskeletal disorders comprise overexertion, upper extrem-
retically less dependent) and surgical (theoretically more depen- ities o lower extremities diseases, among many other disorders.
dent) units previously referred, to test in practice this initially Overexertion, for its part, refers mainly to biomechanical overload
theoretical presumption. Given the low number of cases in the in the lower back, that is, the primal cause of accidents due to
patient handling, as stated in numerous studies (Marras, 2008;
Table 13
Seidler et al., 2009; Menoni et al., 1999). For that reason, acci-
Statistical descriptive study (HEMPA scores).
dents caused by overexertion were separated from musculoskeletal
Units N Min Max Average Standard Deviation Variance disorders to be properly analysed.
Medical 5 11,4 24,9 18,99 5,31 28,29 Later these results were grouped in two risk levels (over 15 and
Surgical 5 10 15,4 13,98 2,25 5,09 under 15), as value 15 is coincident with the midpoint of the total
Mann-Whitney test: Z ¼ 2.619; p ¼ 0,000. score of HEMPA. It was checked by Odds Ratio that in the lowest-
T Student test: t ¼ 3188; p ¼ 0.021. risk group (HEMPA value greater than 15 points) there were
216 A. Villarroya et al. / Applied Ergonomics 65 (2017) 209e222

Table 14 ensure every aspect of its correct application in practice.

Relationship between HEMPA risk levels and accidents by overexertion (number of After finishing the field work, and before performing a statistical
incidents).
analysis, the results of the different methods were standardized,
HEMPA Score (points) Overexertion Other MSDs Total giving values from 1 to 100, according to a scoring logic of assigning
HEMPA<15 26 44 70 a higher score to the situations where risk is lower. Each method
HEMPA>15 16 84 100 was standardized differently, according to its own characteristics,
Total 42 128 170 as follows:
Odds Ratio: 2.227 (IC 1,09e4551). - MAPO. This method offers a lower score the lower is the risk,
unlike other tools. Its scale ranges between 1 and 10. To adapt it to a
0 to 100 scale, each MAPO score was multiplied by 10, making thus
significantly fewer accidents by overexertion (16 accidents), while equivalent to the rest of the methods.
in the highest-risk group (HEMPA value lower than 15 points) there - Care Thermometer. This tool gives a percentage score, in the
were more accidents for the same cause (26 accidents), as observed sense of assigning a higher score the lower the risk so it was not
in Table 14. necessary any standardization. It should be noted that Care Ther-
mometer offers three percentage scores according to different risk
levels (green, yellow and red). In this case, the highest score ob-
11.4. Reliability
tained has been taken as final score, since it is not possible to
average the three values and obtain an overall value that integrates
11.4.1. External reliability
them.
The results obtained with HEMPA were compared with the re-
sults of other specific assessment tools, in particular those used in
- PTAI. This method provides a single final percentage result in
the aforementioned comparison (Villarroya et al., 2016); i.e., MAPO,
scale from 0 to 100, so it was not necessary to make any
DINO, PTAI, Dortmund Approach and Care Thermometer methods.
standardization.
To analyse the functionality of those methods, a previous fieldwork
- DINO. This method provides an ascending scale of 0e1, with
has been conducted in various medical and surgical units of a public
0 being the higher risk and 1 the lowest. Therefore, the scores
health service hospital (Lucus Augusti Hospital, Spain). The same
were multiplied by 100 to adapt them to a 0 to 100 scale.
units were evaluated with all methods, that is, both medical units
- HEMPA assigns a higher score the lower is the risk, from 0 to 30
(Paediatrics, Obstetrics, Psychiatry, Gastroenterology and
points. To be standardized into a 0 to 100 scale, the scores were
Neurology) as surgical units (Traumatology, General Surgery, In-
multiplied by 33,33.
ternal Medicine, Ophthalmology-Urology and Dermatology- Trau-
- Dortmund Approach. This tool does not provide a final risk level
matology). The study was conducted by the main author of this
of the units analysed, so no data was standardized for the as-
article, who has more than ten years of experience working as an
sessments made with Dortmund Approach.
ergonomist in a public hospital. It should be noted that training in
the use of the five methods was acquired before the fieldwork was
Therefore, a descriptive statistical analysis, a study of differences
made, consulting the authors of the different tools its proper use to

Fig. 1. Descriptive boxes diagram (Medical Units).

 A. Villarroya et al. / Applied Ergonomics 65 (2017) 209e222 217

Table 15
T Student, Wilcoxon and Friedman analysis (Medical Units).

T Student Wilcoxson Friedman

Compared Significance Compared methods Significance Significance

Methods
MAPO e HEMPA ,700 MAPO-HEMPA ,415 ,060
CARE e HEMPA ,559 CARE-HEMPA ,327
PTAI e HEMPA ,000 PTAI-HEMPA ,005
DINO e HEMPA ,191 DINO-HEMPA ,241

Fig. 2. Descriptive boxes diagram (Surgical Units).

through a bivariate analysis of repeated samples (with T-Student results of these same experts and those obtained in Lucus Augusti
and Wilcoxon signed-rank tests) and a multivariate analysis (using Hospital applying the HEMPA method. By using the HEMPA
Friedman test) were conducted. Fig. 1 and Table 15 present the final method, all experts have observed and analysed the same two units
results (it should be noted that Dortmund Approach method was (Paediatrics and Traumatology), even though each expert has
not included in the statistical analysis, because this method does observed the corresponding bit at their respective hospitals. Ex-
not allow a final quantitative value). As it can be seen, only PTAI perts inspected at least one room on each unit to evaluate patient's
method shows significant differences with HEMPA, both with T hygiene and in-bed postural changes.
Student and Wilcoxon tests. Regarding the multivariate analysis Considering that HEMPA assigns a higher score to lower risk
with the Friedman test, no significant differences were observed situations, between the range of 0,8 to 30 points, results from a
between methods, although the value of p (0.06) is close to the level medical unit such as Paediatrics ewhere patients show low de-
of significance (0.05), probably due to the differences with PTAI pendency and low patient handling riske were compared using the
method. T-Student test to those obtained from a surgical unit such as
For surgical wards, the results are shown in Fig. 2 and Table 16. Traumatology ewhere patients typically show high dependency
As it can be seen, there are no significant differences in either and higher patient handling riske. Table 17 shows the obtained
bivariate or multivariate analysis. results.
Based on the obtained results, it was concluded that the method As it can be seen in the T Student test, there are significant
HEMPA measures similarly to other specific methods, with the only differences among the results obtained, reaching the highest score
exception of the medical hospital units and regarding PTAI method. (average 21.5) in the lower risk unit (Paediatrics) and the lowest
score (average 14.4) in the higher risk unit (Traumatology).
Consequently, the results of the experts confirm the correlation
11.4.2. Inter-observer reliability between risk levels and scores.
Once the formal and content aspects were evaluated by the
experts, the purpose was to check if there were differences with the
218 A. Villarroya et al. / Applied Ergonomics 65 (2017) 209e222

Table 16
T Student, Wilcoxon and Friedman analysis (Surgical Units).

T Student Wilcoxson Friedman

Compared Significance Compared methods Significance Significance

Methods
MAPO e HEMPA ,314 MAPO-HEMPA ,237 ,308
CARE e HEMPA ,324 CARE-HEMPA ,395
PTAI e HEMPA ,054 PTAI-HEMPA ,075
DINO e HEMPA ,438 DINO-HEMPA ,499

Table 17 in a similar way as other specific methods used in this field.

e HEMPA levels obtained by experts in Paediatrics and Traumatology. Therefore, it can be concluded that HEMPA quantifies, in a valid
Medical Unit Surgical Unit and reliable way, the risks associated with physical overload
Paediatrics Traumatology
resulting from manual handling of patients, and it correctly defines
the exposure levels. Since it is an instrument designed to objec-
Hospital Lucus Augusti 24,9 15,3
tively cover the working conditions related to the handling of pa-
Expert 1 18,5 13,6
Expert 2 21,3 9,7 tients, it is indicated for the assessment of such occupational
Expert 3 19,1 11,6 hazards and for preventing health damage related to its exposure.
Expert 4 22,5 13,3 Nevertheless, although HEMPA focuses on the damage that may
Expert 5 20,8 22,6
affect caregivers, is no less true that when presence of risk is
Expert 6 23,4 14,7
Average 21,5 14,4
detected, a comprehensive approach with multifactor in-
terventions should be adopted for risk reduction. As mentioned in
T ¼ 4141 p < 0,006.
ISO/TR 12296, a comprehensive approach is most likely to be suc-
cessful, but previously based on the results of an analytical risk
assessment. Thus, a proper risk assessment is the basis for appro-
11.4.3. Reliability of internal consistency priate choices in risk reduction that should consider, among other
To check the internal consistency of the ten items of HEMPA aspects, the definition of a general risk management system and
method, we have used Cronbach's Alpha. Cronbach's Alpha was clear policies and procedures by the organization.
calculated with the data obtained for each item in the same medical Finally, we must recognize some limitations of this study. First,
and surgical units referred in validation section (paragraph 3.1). The the identification of risk levels regarding the degree of dependence
final Cronbach's Alpha value was 0,732, demonstrating that the has been limited to five medical and surgical units, and not to the all
homogeneity among the items of the method was achieved. As a the hospital wards. In addition, in order to obtain the method
general rule, and according to various studies (George and Mallery, reliability, results obtained in these units have been compared with
2003; Kaplan and Saccuzzo, 1982; Huh et al., 2006), this coefficient those obtained by other experts in a small number of sections and,
is considered between “good” and “acceptable”, when the final accordingly, it should be expanded to other sections in future
value ranges between 0,7 and 0,8. studies. Also, in the future it would be advisable to calculate odds
ratios for all three categories of HEMPA (red, yellow and green)
12. Conclusions once a larger sized sample has been analysed. Furthermore, the
validation has been carried out exclusively in inpatient units of a
HEMPA is an assessment tool mostly based in the observation of mid-size hospital, and not in a big hospital, either in operating
workplaces where patient handling takes place regularly. It is a rooms or in other socio-sanitary environments such as home care.
method that should be used by a qualified professional through a These aspects should be considered in future developments of this
checklist designed for this purpose (see Annex), following a scoring work.
criteria. This tool, recommended to be used in the hospital setting,
particularly in hospital wards where patients are handled, aims to
provide a quantitative final result to determine whether the level of Annex. checklist
risk of musculoskeletal disorders during patients transfer is
acceptable, moderate or unacceptable for the caregiver, regarding Patient handling assessment method “HEMPA”
the patient's degree of dependence.
The validity of the method has been tested successfully in both Unit data (descriptive, no score).
its formal and content aspects by a panel of experts in healthcare
ergonomics, that have agreed that this is a suitable tool for the
purposes pursued. Regarding the construction validity, it has been
found that the method quantifies correctly risks regarding the pa- Unit data

tient's degree of dependence. Additionally, it has also been found Assessment Date: Hospital/Health Center: Unit or Service:
that the method correctly estimates the units with higher risk, Number of workers performing patient handling
Nurses: Nurses assistants: Orderlies: Others:
regarding the previously registered accidents by overexertion. In
terms of reliability, it has been found that the items of the method
are homogeneous with each other. Also the method provides
similar results after being used by different experts and it measures
 A. Villarroya et al. / Applied Ergonomics 65 (2017) 209e222 219

1 Dependency level

1. Dependency level

a. Patient mobility (It must be checked the mobility level of patients Level A , Independent patient (3p)
and the handling type, from safe to unsafe) Level B , Patient with walker (2.40p)
Level C , Partial support (1.80p)
Level D , Dependent patient (1.20p)
Level E , Bedridden (0.60p)
Sub-Total A: Patient 1: Patient 2: Patient 3:
b. Patients collaboration Level 1 , Fully co-operating (3p)
(It must be checked the collaboration level of patients and the handling type, from safe to unsafe) Level 2 , Partially co-operating (2p)
Level 3 , Non co-operating (1p)
Sub-Total B: Patient 1: Patient 2: Patient 3:
TOTAL: (Sub-Total A þ Sub-Total B)/2 Patient 1: Patient 2: Patient 3:

2 Environmental conditions

2. Environmental conditions

Temperature and humidity conditions (Measure to check Temperature (14
C - 25
C) Room 1 Room 2 Room 3 , Appropriate (0.25p) , Inappropriate
minimum health and safety requirements at workplaces) Humidity (30%e70%) Room 1 Room 2 Room 3 , Appropriate (0.25p) , Inappropriate
Lighting (500 Lux) Room 1 Room 2 Room 3 , Appropriate (0.25p) , Inappropriate
Acoustic discomfort (40 dB: 7:00 and Room 1 Room 2 Room 3 , Appropriate (0.25p) , Inappropriate
23:00 h, 30 dB 23:00 and 7:00)
TOTAL Room 1: Room 2: Room 3:

3 Workspaces

3. Workspaces

Workspaces (Consider bathroom access, toilet characteristics, Bathroom Room 1 Room 2 Room 3 , No obstacles access (0.625p)
possibility of regulation of beds to handle patients at an , Door width and spaces (0.625p)
appropriate height and room spaces to perform handling in a safe way) WC Room 1 Room 2 Room 3 , Toilet height and support bar (0.625p)
, Wheelchair (0.625p)
Height-adjustable Room 1 Room 2 Room 3 , Height and tilt of beds (1.25p)
beds
Rooms Room 1 Room 2 Room 3 , Space between beds (0.625p)
, Space to the wall (0.625p)
TOTAL Room 1: Room 2: Room 3:

4 Minor aids

Mechanical aids - Previous requirements to consider for each existing aid

Prerequisites compliance Safety requirements Aid 1 Aid 2 Aid 3 , Appropriate state

(Observe and verify the safety and adaptability , Adequate training for its use
requirements of each existing minor aid) , The aid facilitates a safely handling
Adaptability requirements Aid 1 Aid 2 Aid 3 , The aid is on the unit, and in sufficient number
for all cases in which it should be used.
, Adequate for handling
REQUIREMENTS COMPLIMENTS Aid 1: Aid 2: Aid 3: , YES , NO

4. Minor aids

Minor aids Assistive products for transfer and turning , Transfer platform. (1.25p)
(Only score each aid if it previously meets all the , Rotating disk or turntable (1.25p)
requirements of table “Mechanical aids-Previous Requirements”) , Sliding sheet. (1.25p)
Assistive products for walking , Walker or standing hoist (1.25p)
TOTAL
220 A. Villarroya et al. / Applied Ergonomics 65 (2017) 209e222

5 Major aids

Mechanical aids - Previous requirements to consider for each existing aid.

Prerequisites compliance Safety requirements Aid 1 Aid 2 Aid 3 , Appropriate state

(Observe and verify the safety and adaptability , Adequate training for its use
requirements of each existing major aid) , The aid facilitates a safely handling
Adaptability requirements Aid 1 Aid 2 Aid 3 , The aid is on the unit, and in sufficient number
for all cases in which it should be used.
, Adequate for handling
REQUIREMENTS COMPLIMENTS Aid 1: Aid 2: Aid 3: , YES , NO

5. Major aids

Major aids Assistive products for lifting , Patient Lift (1.25p)

(Only score each aid if it previously meets all the Assistive products for personal mobility , Wheelchair (1.25p)
requirements of table “Mechanical aids-Previous Requirements”) , Height-adjustable bed (1.25p)
, Height-adjustable stretcher (1.25p)
TOTAL

6 Transfer execution and postural analysis

6. Transfer execution and postural analysis Handling execution Safe execution (no awkward postures adopted)

Yes No Acceptable (0.40p) Unacceptable

Lift a patient into a seated position. Patient 1 Patient 2 Patient 3

Move a patient towards the bed's head Patient 1 Patient 2 Patient 3
Move the patient to one side of the bed. Patient 1 Patient 2 Patient 3
Raise patient's legs. Patient 1 Patient 2 Patient 3
Incline the bed's head. Patient 1 Patient 2 Patient 3
Shove a bedpan. Patient 1 Patient 2 Patient 3
Place minor aids. Patient 1 Patient 2 Patient 3
Transfer the patient from bed to bed. Patient 1 Patient 2 Patient 3
Place from bed into a chair Patient 1 Patient 2 Patient 3
Raise the patient from sitting to standing position Patient 1 Patient 2 Patient 3
TOTAL: Patient 1: Patient 2: Patient 3:

7 Handling outcome

7. Handling outcome

Handling completion and patient position The transfer technique used causes no pain to the patient. Patient 1 Patient 2 Patient 3 , Happens (0.5p)
, Does not happens
The transfer technique causes no fear or uncertainty to the patient. Patient 1 Patient 2 Patient 3 , Happens (0.5p)
, Does not happens
Transfer is not done quickly or rushing. Patient 1 Patient 2 Patient 3 , Happens (0.5p)
, Does not happens
At the end of the transfer the patient is in a functional position. Patient 1 Patient 2 Patient 3 , Happens (0.5p)
, Does not happens
TOTAL Patient 1: Patient 2: Patient 3:

8 Work organization

8. Work organization

Work organization Ratio patient -caregiver. Ward 1 Ward 2 Ward 3 , Appropriate (0.5p)
(Consider the patients' ratio per caregiver, the , Inappropriate
night-time service, the peer support for handling patient, the work pace and breaks) Nocturnity Ward 1 Ward 2 Ward 3 , No night work. (0.25p)
, Rest (0.25p)
Peer support. Ward 1 Ward 2 Ward 3 , Yes (0.5p)
, No
Work pace and breaks. Ward 1 Ward 2 Ward 3 , Time pressures (0.25p)
, Periodic breaks (0.25p)
TOTAL Ward 1: Ward 2: Ward 3:
 A. Villarroya et al. / Applied Ergonomics 65 (2017) 209e222 221

9 Training

9. Training

Specific training in Information about risks related to manual patient handling in the workplace. Ward 1 Ward 2 Ward 3 , Yes (0.5p) , No
manual patient handling Theoretical and practical training in manual patient handling imparted to at least Ward 1 Ward 2 Ward 3 , Yes (0.5p) , No
75% of the employees of the unit.
Practical training in the use of mechanical aids imparted in the last two years. Ward 1 Ward 2 Ward 3 , Yes (0.5p) , No
Verification of the training validity, regarding its effectiveness in reducing accidents. Ward 1 Ward 2 Ward 3 , Yes (0.5p) , No
TOTAL Ward 1: Ward 2: Ward 3:

10 Risk perception

10. Risk perception Yes (0.25p) No

a. Do you think that the working postures adopted during patient handling pose no damage to your health? Worker 1 Worker 2 Worker 3
b. Are patients transfers planned in advance? Worker 1 Worker 2 Worker 3
c. In your opinion, the patients handled are light or moderately heavy? Worker 1 Worker 2 Worker 3
d. Patients transfers are not continuous or occur spaced along the work shift? Worker 1 Worker 2 Worker 3
TOTAL (Divide the total score obtained by the number of workers who answered)

Final risk level of the unit

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