Barriers to Implementation and Effective Strategies for Change Management

The dissertation discusses the importance of implementing a Safe Patient Handling and Mobility (SPHM) program to reduce musculoskeletal injuries among nurses. It highlights the barriers to implementation, such as lack of support from higher authorities and shortage of human resources. The study also emphasizes the need for ethical considerations, including dignity, trust, and risk reduction. Additionally, it recommends establishing a SPHM program in local hospitals, developing a standard policy and checklist for nursing health and safety, and creating a national auditing tool to evaluate the effectiveness of service implementation.

Dissertation

TABLE OF CONTENTS
Safe patient Handling and Mobility program(SPHM) to reduce musculoskeletal
disorders (MSDs) injuries among nurses......................................................................3
Chapter 1 .......................................................................................................................3
1.1. Introduction.............................................................................................................3
1.2 Dissertation Aim.......................................................................................................5
Chapter 2........................................................................................................................6
Literature review ...........................................................................................................6
2.1 Literature Review (LR)............................................................................................6
2.2 Search strategies ......................................................................................................6
2.3 Safe patient handling and mobility(SPHM) program in control of Musculoskeletal
disorders (MSDs) injuries with nurses in work environment.........................................7
2.4. The barriers that avoid SPHM program from implementation.............................12
Conclusion....................................................................................................................14
Recommendation for local services improvement:......................................................14
Chapter 3......................................................................................................................15
Quality improvement (QI)............................................................................................15
3.1.The importance of leadership in facilitating improvements...................................15
3.2.Leadership in health care organisations.................................................................16
3.2. Leadership theories................................................................................................17
3.4. Leadership styles...................................................................................................17
3.5. Introducing SPHM program in local practice.......................................................19
Recognition..................................................................................................................19
Analysis........................................................................................................................20
Preparation....................................................................................................................20
Implementation.............................................................................................................21
Plan...............................................................................................................................21
Do.................................................................................................................................22
Study.............................................................................................................................23
Act................................................................................................................................23
Evaluating the Change..................................................................................................23
Sustaining the change...................................................................................................23
Barriers to implementation...........................................................................................24
Ethical consideration....................................................................................................24
Chapter 4 .....................................................................................................................24
4.1.Conclusion .............................................................................................................24
4.2.Recommendation....................................................................................................25

SAFE PATIENT HANDLING AND MOBILITY PROGRAM
(SPHM) TO REDUCE MUSCULOSKELETAL DISORDERS
(MSDS) INJURIES AMONG NURSES
CHAPTER 1
1.1 INTRODUCTION
Safety of nurses in any health institution is an important part to achieve
maximum level of care and services along with continuity of work. Nowadays, many
health issues were raised in the nursing field that negatively affects influence of work
environment work on nurse’s health. Nurses and other healthcare workers face many
hazards in their work environment. Health care environment can be considered to be
the most hazardous. (The Facility Guidelines Institute, 2012). As it is shown by the
Bureau of Labour Statistics, (2012) healthcare and social assistance workers
experience the highest rate of non-fatal occupational injuries and diseases in
comparison to any other sector such as manufacturing and construction. For instance,
more than 600 injury cases per 10,000 full time workers (appendix1) in healthcare and
social sector (Bureau of Labour Statistics, 2012). In addition, according to one survey
drawn from 53 healthcare systems with roughly 1,000 hospitals in all 50 states,
patient handling injuries accounted for 25 percent of all workers’ injuries for the
healthcare industry in 2011 (OSHA, 2013).
The most common and frequent nursing activities are lifting, transferring and
repositioning. Various studies were referred to most of injuries in nursing work
environment that happened from lifting and moving of patients (Howard, 2010).
Lifting and moving patients is the major cause of injuries and musculoskeletal
disorders (MSDs) with nurses (Waters, 2007). Such tasks could result in micro
injuries to the spine (Waters, 2007). Various studies evident that repeated and forceful
movements during providing care and nursing activities could cause major injuries
and MSDs (Nelson and Baptiste, 2004). The nurses could not feel the effects of these
activities immediately but after period of time from practicing such tasks this micro
injuries lead to debilitating injuries (Howard, 2010). As statistics shown by American
Nurses Association (ANA) survey (2011), 62% of nurses reported “developing
MSDs”, 56% of nurses say that they have experienced musculoskeletal pain that
became worse by their job and 80% of nurses reported pain due to MSDs report work
despite experiencing frequent pain. In the UK, back pain and MSDs account for

approximately 40 per cent of all occupational ill health (National Health Services
(NHS), 2009).
MSDs can be defined as pain in the affected body region (e.g., back or neck)
for a specified duration or frequency (Bernard, 1997) along with other related
symptoms such as numbness and tingling (Jonsson, et al., 1987). Measurement of
MSDs vary from study to study. Many studies were using different ways of
measurement such as self-report and others requiring care or obtaining testing or
diagnosis by a physician. Hoogendoorn and colleagues (1999) observed the health
care workers through video and questionnaires during 3-year. They found that over
exhausted and forceful movement and lifting had a strong influence on the worker’s
low-back pain.
As per the above finding, it is vital to establish program that aimed to reduce
the rapid raise in nursing MSDs injuries related to handling and mobility of patients in
the work environment. Since decades, many health organisations and institutions were
establishing policies and regulations in order to ensure and manage Health and Safety
for nurses Working. For example, in UK, the Health and Safety at Work Act (1974)
was established regulation related to Management of Health and Safety at Work
Regulations and Workplace (Health, Safety and Welfare) Regulations (NHS, 2009).
Traditional strategies were used to reduce the MSDs injuries such as (1) sessions in
body mechanics, (2) training in safe lifting techniques and (3) back belts. In fact, the
above strategies are based on tradition rather then on scientific evidences (Nelson and
Baptiste, 2004, Hignett. et al., 2003, Ignatavicius & Workman, 2013). Nowadays,
many evidence-based practice strategies were implemented such as; (1) patient
handling by equipment/devices, (2) no-lift policies, (3) training on proper use of
patient handling equipment/devices and (4) patient lift teams. According to the
Occupational Safety and Health Administration (OSHA), “almost all successful
injuries and illness prevention programs include six core elements which are (1)
management leadership, (2) employee participation, (3) hazard identification and
assessment, (4) hazard prevention and control, (5) education and training, and (6)
system evaluation and improvement” (OSHA, 2014).
Moreover, The Nurse and Health Care Worker Protection Act of (2013) was
established program that aimed to decrease incidence of injuries of health care
workers (H.R.2480-113th Congress, 2013-2014). One aim of this program was to
eliminate the manual lifting of patients by direct care staff (Nurse). In addition, the

program was encouraged to use of handling equipment; the percentage exposure to
lifting injuries was reduced up to 95%. Using of lifting equipment provide extra
benefits on health and safety of workers such as more satisfying working
environment; improved nursing recruitment and retention as well as reduced costs
associated with injuries.
As a result, evidence-based research has approved the success of program
where the rate of injuries among health workers decreased (OSHA, 2014).
1.2 Dissertation AimPresent dissertation has been evaluating the
effectiveness Safe Patient Handling and mobility (SPHM)
program to reduce MSDs with nurses in direct care units.
Additional aim for this dissertation is to promote the use of
SPHM program in local hospital to prevent health worker’s
(nurses) MSDs injuries as nurses are forefront of health care
delivering.
The next chapter is based on relevant literature review (LR) on requirement of
SPHM program for nurses to reduce MSDs injuries.
CHAPTER 2
LITERATURE REVIEW
2.1 Literature Review (LR)
This chapter is used for the purpose of carrying out research study in a
systematic manner and it is basically related to collecting data as per the subject
matter (Rees, 2011). It is also the most significant section of research study in which
researcher accesses papers, research articles and journals. This section also includes
review of secondary sources for the purpose of specifying suitability of topics.
2.2 Search strategies
Search strategy has been identified after selecting the aim of dissertation;
hence, operation plan is made accordingly. These strategies are used for the purpose
of searching content for study. Further, it is a process that starts from actual searching
and browsing of the collection of data. Different search terms are being used for the
study so that suitable data can be collected. Various key words are being used along
with unique strategies which would also work in electronic database and manual

search of books in Oman Specialised Nursing Institute library. Furthermore, in the
study, Critical Appraisal Skills Programme (CASP) checklist has also been used for
the purpose of evaluating evidence for clinical effectiveness (NCCMT, 2011). With
the help of this checklist, reliable and trustworthy data is being researched as per the
subject matter.
Table1
Key words Database
Ergonomic practice ,Lifting equipment,
Musculoskeletal injury Nurse Organizational
culture, Safety climate ,Safe patient handling
Safe work practice
Musculoskeletal disorders; patient handling,
work injuries; work injury costs; safe patient
handing and movement.
The Cochrane Library( Medline, CINAHL,
NCBI(The National Centre for Biotechnology
Information), Pub Med, Elsevier library,
online library, MoH library
MoH Library
Table 2
inclusion criteria Exclusion criteria
Research studies done after 2011to 2016
have been included.
Studies done prior 2011 have not been included in
the research work.
English language studies. Non English studies.
MSDs injuries in nursing working
environment.
Rule out non work-related MSDs injuries in
nursing work.
The selected studies
Type of studies used Total number
Systemic review (SR) 3
Randomised control trail(RCT) 1
Qualitative descriptive 1
Cross-sectional Survey 3
The themes that emerged from LR are:

1- Safe patient handling and mobility program in control of MSDs injuries with
nurses in work environment.
2- The barriers that avoid SPHM program from implementation.
2.3 Safe patient handling and mobility (SPHM) program in control of musculoskeletal
disorders (MSDs) injuries with nurses in work environment
Based on the vital role of nurses in healthcare process; specific attention from
health institutions and organisations is needed to preserve them health and safety
when it is practised during duty. Wide range of literatures state that nurses are expose
to injuries in their environmental work. Next paragraph will review different
literatures regarding prevalence of MSDs injuries among nurses and proper preventive
interventions to reduce it.
Bos et al., 2007 conducted cross-sectional study which indicated the
prevalence of MSDs among healthcare workers (IC nurses, operation room nurses,
and X-ray technologists, and non-specialized nurses). Cross- sectional study can be
defined as ''collecting data at one point in time with no follow-up’’ (Fain, 2009, p25).
The sample consisted of 3,169 employees in eight university hospitals in the
Netherlands. The employees were asked whether they had low back or neck-
shoulder pain during the past year. The results have shown that four professional
groups had high rates of musculoskeletal complaints: low back 76% and neck-
shoulder 60%.
Similarly, Karahan et al. 2009 conducted cross-sectional survey which aimed
to study the prevalence of MSDs and risk factors amongst a variety of Turkish
hospital healthcare workers such as nurses, physicians, physical therapists,
technicians, secretaries and hospital aides. Questionnaires were distributed in Six
Turkish university hospitals. 1600 employees have completed it. 65·8% of
participants had reported low back pain. The highest rate of back pain recorded by
nurses was 77·1%.
Both studies i.e. Karahan et al. 2009 and Bos et al., 2007 analysed that there
are various causal factors that increase the potential to have MSDs injuries such as
working activities involving twisting, bending, heavy lifting, improper posture and
psychological stress.
Therefore, Karahan et al. 2009 and Bos et al., 2007 recommended specified
preventive interventions to be implemented for each healthcare worker especially

for nurses. For example, arranging proper rest periods, educational programmes to
teach the proper use of body mechanics handling devices and smoking cessation
programmes.
Wide range of literatures that examining effectiveness of Safe patient handling
and mobility (SPHM) program in order to decrease MSDs injuries with nurses.
Evaluating the effectiveness of SPHM program can be through three dimensions;
engineering (modifying suitable work environment through, layout, tools or
equipment used), administrative (modification of job rules and procedures and
financial support of training sessions and purchasing of handling and lifting
equipment) and behavioral (training of staff nurse in body mechanics, training in
proper use of lifting equipment/devices) controls (Kurowski et al.2017 , S.-J. Lee and
J.H. Lee, 2017).
Similarly, Van Bogaert et al. (2013), conducted cross-sectional survey to
explore the nursing practice environment had effect on job outcomes and Nursing care
quality. Questionnaire was used to collect data from 1201 nurses that have
participated in the survey. The survey examined the way in which work is structured
and organized to support nurse’s well-being and safety, team performance, safety and
quality of patient care. Researchers confirmed that leaders should involve staff nurses
on the process of decision-making regarding care process. Hence, nurses are the direct
care staff that interfere in patient’s care process. Moreover, this survey highlights
importance of optimising environment for the best nursing practice.
A systematic review (SR), was undertaken by I. Rivilis et al, 2008 to evaluate
the participatory ergonomic (PE) interventions/program for improving the health of
healthcare worker. PE can be defined as ‘the involvement of people in planning and
controlling of their own work activities with sufficient knowledge in order to achieve
required institute goals (’Wilson and Haines, 1997). SR is process that reviews
literatures with using specific criteria to focus on the important details of evidence
(Rees, 2011). However, it is not introducing new evidence in current clinical practice
being examined.
This SR studied 23 articles which met the required criteria from 1994-2002.
12 studies were classified as ‘medium’ or higher, it provided evidence that PE
program has a positive influence on: decreasing musculoskeletal symptoms, injuries
and reduction in absence days from work due to sickness. Six electronic databases
were searched i.e. Medline, Excerpta Medica database (EMBASE), Cumulative Index

to Nursing & Allied Health Literature (CINAHL), Canadian Centre for Occupational
Health and Safety (CCINFO web), Safety Science and Risk as well as Ergonomic
Abstracts. All these databases are considered as professional and are globally
accepted (Rees, 2011).
The main idea of applying this program is formation of an ergonomics team
(managers, health and safety personnel, research experts). Those people undergo
training to develop new knowledge to make improvements in the workplace (Wells et
al., 2004). These studies were monitoring the improvements in health outcomes by
examining process of implementation, changes in exposures and effects on health
outcomes after application of this program.
The most PE interventions were providing training sessions from 1 hour to 20
hour on technical tasks (Bohr, 2000; Carrivick et al., 2001; Evanoff et al., 1999;
Wickstro¨m et al., 1993, Ketola et al., 2002). Another intervention was
implementation of changes to the physical design of equipment and workplaces,
changes in work tasks as well as in formulation of policies (Carrivick et al., 2001;
Moore and Garg, 1998). Another study in this SR created a stretching and exercising
program or improving physical status of workers, maintaining procedures for used
equipment and designing new rooms for rest-breaks (Wickstro¨m et al., 1993,
Laitinen et al., 1997a, Halpern and Dawson, 1997, Evanoff et al., 1999).
The results have shown from 6 out of 12 studies that there is reduction of
MSDs symptoms. In addition, notice reduction of MSDs symptoms are record. As a
result of this, percentage of absence days related to MSDs symptoms was also
decrease.
Another SR was conducted by Jefferson (2010) where 99 articles were
reviewed and 23 articles only met the established criteria. The aim of this SR was to
determine the best interventions in a hospital setting that can reduce patient handling
injuries among healthcare workers. 9 out of 23 articles reflected decrease in injury’s
rate related to lifting patients among healthcare workers. Combination of articles has
shown that use of handling equipment had a great role in reducing the MS injuries
rate. The most studies pointed successful components of SPHM program
implementation are; educational training sessions and availability of handling
equipment's.
In contrast to I. Rivilis et al, (2008) findings related to ergonomic intervention
program made by H.J. Lim et al., (2011) have shown that handling injuries is the most

common among healthcare workers especially nurses. Therefore, ergonomic
intervention program in SPHM is required to reduce the risk of MSDs injuries among
nurse’s personnel. This program encouraged to provide right handling equipment and
training of workers to develop effective practices for handling and lifting of patients.
The data were studied during 2 years pre-intervention and 2 years post-
intervention. The results indicated that intervention group had a 38.1% lower repeated
MSDs injury as compared to the control group (p=0.0005). In addition, sick leave and
time loss days were significantly decrease by 55% in the intervention hospitals (from
36 days to 16.2 days).
Kurowski et al, (2016) supported the previous study’s findings that MSDs
injury’s rate was reduced substantially within three years of beginning
implementation of SPHM program. 136 nursing homes with average annual
employment of 18,571 fulltime equivalents are included in the study over period of 8-
years. Large sample of study was used over long period of observation. Large sample
size increases the reliability and validity of study (Fain, 2013). Reliability examines
the accuracy of data collection method by applying various tests. Whereas, Validity
assesses the extent to which data assembled in research paper is what was proposed to
be collected and examined (Rees, 2011). The main interventions of the program were;
nurse’s training, purchase of mechanical transferring and mobility devices and
detailed maintenance protocols. As training is highly recommended for successful
implementation of SPHM program (Thomas and Thomas, 2014; Hodgson et al.,
2013); Massachusetts Department of Public Health Occupational Health Surveillance
Program, 2014). Results have shown the success of SPHM program and
improvements continued for six years after the SPHM program was implemented.
Randomised Control Trail (RCT) was conducted by Theis. et al, (2013) which
aimed to evaluate the effectiveness of SPHM program in reducing injury due to
patient lifting. RCT is considered as the most accepted research method to examine
and evaluate the intervention in large group sample (Fain, 2013). All those
participants were chosen randomly and did not receive any training sessions in SPHM
program. Randomization process in choosing the participants reduces risk of biasness
in the study (Grove. Et al, 2015). Bias refers to any factor that may affect the accuracy
of results in study (Rees, 2011). 55(98.2%) out of 56 participants (nurses) agreed to
participate in this study. The competency were examining by checklist (Staff Patient
Transfer Pre Competency Check-Off List); to examine the level of knowledge in safe

transferring of patients and evaluate who need additional training. This checklist
decreases the risk of bias and increases validity of information that was collected
(Fain, 2013). As a result of this, all participants received training sessions on SPHM
from October 2004 through June 2005. Researches were following the results of study
through three time periods (1) Baseline: 1/1/2002–9/31/2004, (2) Post Training:
7/1/2005–12/31/2006 and (3) Long Term: 1/1/2007–6/30/2009.
Results are being measured by putting expected and baseline results as shown
in Appendix 2. The number of nurse’s injuries were significantly reduced at post
training as compared with baseline data (p < .001). When measurement is equal or
less than 0.5 P, then value point to an accepted and notable result (Fain, 2013).
The above study recommended to continue training in SPHM to maintain low
MSDs injuries with nurses in environment work. When there is lack of training, then
it may return back the numbers of MSDs injuries to baseline.
Washington State Department (WSD) of Labour and Industries conducting a
5-year study after implementation of SPHM (2007) at Washington state Hospitals. All
the hospitals of SPHM are included in program by survey and interviewing of the
health worker staffs and administrative staffs about; training of direct care staff,
handling policies, procedures, handling devices purchasing and overall program
implementation through 2007, 2009 and 2011.
This program achieved a great success in reducing rate of MSDs injuries
among health workers. This is commonly known with the direct care staff is that ''no
SPH policy''. 20% of respondents reported either not having or not knowing if they
had a SPH policy. According to SPHM program implementation, the percent of '' No
SPH Policy'' decreased from 20% in 2007 to 3.6% in 2009. This refers to increase the
awareness and knowledge about written policies related to handling and transferring
patients. Moreover, the reporting rate of injuries related to transferring patient
increased from 2007 to 2009. This is due to increased knowledge about a committee
that discusses patient’s handling injuries of staff (p<.001). The staff has become more
aware and they do not accept musculoskeletal pain as “just part of the job”. Therefore,
the percentage of MS symptoms decreased as shown in appendix2. Additionally, the
respondents reported high proportions of using of SPH equipment in both 2007 and
2009. This results evident that the direct health worker (nurses) became capable to
handling equipment properly and effectively.

Overall, SPHM program intervention has been shown to be effective in
reducing MSDs injuries among nurses. Therefore, it is recommended for health
organisation to implement this program in the hospital. However, nurses and the
health organisation may face difficulties in implementing such intervention. The next
part of this chapter will discuss obstacles and barriers that they faced and solutions to
overcome the same.
2.4. Barriers that avoid SPHM program from implementation
Although the previous studies (I. Rivilis et al, 2008, Silverstein, 2011,
Kurowski et al., 2016, S.-J. Lee and J.H. Lee, 2017, Theis. et al, 2013,) confirmed the
efficacy of SPHM program in reduction of MSDs injuries among nurses. There are
various barriers and challenges that limit the aim of it. Most of the barriers avoid
SPHM program from implementation are related to people, education, time,
environment and equipment.
Regarding the environmental barriers; implementation of ergonomic
interventions require high efforts and resources (Rayan, 2011). The design and order
of rooms in hospital are not prepared for extra modification (Elnitsky,et .al, 2014).
Silverstein, (2011) stated that in the report of Washington State Hospital
Association’s Environmental Survey, most of the hospitals included in survey
reported that room sizes (66%) is the major challenge to apply this program as
compared to other factors. 30.5% of respondents reported that lifting equipment need
enough space storage which results in inaccessibility of lift devices. For example:
they were arranged in the end of the hall/room. Moreover, (30%) of respondents
pointed out the equipment size that limit the practicality of using it. Additionally, high
cost of handling and lifting equipment (17.5%) (Silverstein, 2011) will remain a
barrier due to lack of fund from the higher authority (Hallmark et al. 2015).
Secondly, shortage of staff (50%) and heavy workload has become the second
challenge in applying this program (Silverstein, 2011). SPHM program need
sufficient number of staff nurse’s recruitment to be implemented effectively. From the
side of patient, most of them want immediate mobility and the use of equipment
devices will take time (32%). Alamgir, et al. (2009) confirmed that transfers
performed manually required on average less time (bed to chair transfers: 156.9
seconds, by using assistance devices it will need, 273.6 seconds). So, healthcare

provider will prefer short time procedure of handling due to staffing shortage and
work overload.
Regarding mobility equipment, the survey has shown that staff nurses are
unfamiliar with new devices (14.5%) due to ineffective training sessions and lack of
regular updating practice related to SPH (Silverstein, 2011). Lack of expert trainers in
SPHM program factor participated for reducing the level of awareness and knowledge
of SPHM program objectives. Furthermore, many studies evident that the nursing
school curriculums lack in promoting knowledge and skills related to SPHM (Hughes,
2006). Therefore, nurse's behaviour is difficult to change because they tend to practice
some activities as they learned from nursing school with slight modifications during
work experience for a long time (Elnitsky et al. 2014).
Most of the studies reflect difficulties in measuring rate of MSDs injuries
accurately because maximum injuries in nursing are cumulative in nature (Hallmark
et al. 2015, Kurowski et al., 2016). Moreover, it needs a long-term evaluation to
confine the advantages and disadvantages of SPHM program (Theis et al. 2013).
As the above studies shown many barriers faced by SPHM program
implementation, many of them provided solution to overcome these obstacles.
Regarding knowledge, Hughes, (2006) recommended to include SPHM interventions
in nursing school curriculums and specify practical class to train the nursing students
on proper body techniques and using of handling devices. Administratively, reviewing
of policies, job description and legislation of handling and lifting patients is required
to update them based on evidence practice (Silverstein, 2011, Kurowski et al., 2016).
Secondly, recruitment of staff need to be done for nurse to solve shortage problem.
Moreover, assigning certain health workers to follow the SPHM program
implementation to provide annual report to higher authority which clarify the
problem(increase MSDs rate among health workers) to aid in financing them with
proper support to modify hospital environment and purchasing of equipments that can
be handled (Silverstein, 2011, Elnitsky, et .al, 2014).
Conclusion
This dissertation aims to review existing literature to evaluate the effectiveness
of SPHM program in reducing MSDs injuries among nurses. From the review, it can
be concluded that SPHM program interventions has reduced MSDs injuries. The
review highlighted the nursing perception regarding SPHM interventions and the

barriers they faced in using SPHM intervention. Consequently, the review pointed out
importance of training and educational sessions in changing traditional knowledge
and updating them with new evidence based practice of handling and lifting patient
safely.
Recommendations for local services improvement
Nurses seeking to use SPHM interventions for MSDs injuries management
often faced barriers. Therefore, it is critical to develop strategies to improve the
quality of these services to provide maximum care for patient and preserve nurses'
health and safety during practicing their duties.
Ministry of Health (MoH) in Sultanate of Oman directs its strategies to
improve the health services for healthcare providers and recipients. ONMC (2012)
emphasises that Omani nurses must practice safe and effective care by acquiring the
latest knowledge and skills based on evidence practice.
(Rivilis et al, 2008, Silverstein, 2011, Kurowski et al., 2016, S.-J. Lee and J.H.
Lee, 2017, Theis. et al, 2013, Rayan,2011, , Hughes, 2006, Hallmarket al. 2015)
highlight that education sessions for nurses in SPHM program are highly helpful to
implement this program effectively and gaining service improvement.
Next chapter will discuss the implementation of service improvement among
direct care nurses in local hospital through educational sessions that led to expand the
use of SPHM program interventions to reduce prevalence of MSDs among nurses.
CHAPTER 3
QUALITY IMPROVEMENT (QI)
From the previous chapter, SPHM program interventions were identified as
management techniques for controlling spread of Musculoskeletal (MS) symptoms
among staff nurses. Findings in above chapter have clearly shown the need for such
program to be implemented in healthcare organisations.As mentioned by MoH
(2014), each healthcare organisation must improve the nurse’s knowledge and skills
regarding introducing safe care. Quality improvement can be defined as an approach
in which the worker’s performance can be analysed in order to improve it (Apekey,
2010). Nationally, MoH (2014) directs the efforts to continuous training and
education are strategies for staff nurse’s development to achieve maximum quality of

healthcare. Therefore, this dissertation will focus on implementing the strategies as a
proposal for SI regarding nurse’s safety in work environment.
3.1 Importance of leadership in facilitating improvements
Service improvement (SI) is important in health care settings as it aims to
spread of the perfect clinical practice (Maher and Benny, 2005). It can be applicable
through utilisation of evidence based practice from the latest updated health care
researches and studies (Royal College of Nursing, 2015). SI can be defined as
combination of the quality improvement techniques with effective organisational and
leadership development (Granville, 2006). Any new issue in health care setting has
barriers and obstacles needed for planned and strategic change before implementing
same in real practice (AlSawai, 2013). Based on the vital role of nurses, there is a
persistent need to establish program that directs the attention to nurse’s safety in work
environment. Such program in nursing safety can offer clear progress in providing the
perfect healthcare.
In UK, improvements of health care services rely on National Health Services
Foundation (NHS) which aims to achieve perfect services built on the latest evidence
practice. Similarly, Oman Ministry of Health (MoH) is responsible for the provision
of maximum health care services to citizens. MoH is constantly developing the plan in
every five years to overcome any barrier that can deny the process of health care
services improvement (Al Dhawi and West, 2014). Moreover, Oman’s health vision
2050 emphasises on the importance of service improvement strategies in the coming
33 years. Under the guidance of NHS and Oman vision 2050, SI and leadership
management skills are important in process of change based on evidence-based
practice. SI is important in overcoming of obstacles and challenging that are face in
health care services and achieving better quality of care and higher worker satisfaction
(Marquis and Huston 2012). Therefore, effective leadership skills are needed in
change process for customers (patients and nurses services satisfaction (Gopee and
Galloway 2014), which will be further discussed and explored in the coming section.
3.2 Leadership in health care organisations
Gopee and Galloway, (2014) stated that health services were administered
rather than managed. Therefore, leadership experienced distinctive changes and
rebuilding stages to create diverse styles that fit with health care organizations. In
1967, Cogwheel report involved direct health care leaders in the management of

health care institutions. Griffith’s report 1983 changed the health organisations’
management so that it is closer to corporate sectors (Gopee and Galloway, 2014).
NHS developed and updated clinical leaders. As Lord Darzi’s reviewed in 2008, this
system gave the leaders of health care management authority over policies and
financial budgets. As leadership enter policies of health care organization; increasing
the discussion about its role in development of health care services (Schyve 2009).
Schyve emphasised on the personality of leaders in motivating inner subordinate’s
competencies in order to increase worker’s achievement and customer satisfaction.
Health care quality can be measured by the safety of health care providers (Nurses)
and recipients (Patient) (Sharma and Jain 2013). Leadership can be defined as
inspiration of others to perform well and achieve challenging goals of institution.
Sharma and Jain (2013), Helmrich (2015) agreed that leadership has broad insight on
facilitating employees’ empowerment and teamwork engagement skills. In terms of
service improvements, it can be said that it is effectual for the nurses to engage
patients as their partners in practice improvements. This is essential so that patients
can also help the nurses in conducting all activities that are relevant. At the same time,
it is also crucial in terms of developing better relationships with the patients
(McNamara, 2015). This is vital so as to enhance the practice of service provision and
patient-nurse relationship can also be developed accordingly. Therefore, nurses
should be updated with advanced knowledge and skills relying on the latest evidence-
based practices.
3.3 Leadership theories
Since, a debate has been are leaders born or made? Despite everything exists
and was driven for leadership theory development. There are many leadership theories
among which the most commonly used and discussed are trait theory as well as
behavioural and situational (Gopee and Galloway 2014). Kumar and Khiliji 2015,
suggested a way to link the leadership theories. They consider the trait theory as one
focused on inherited characteristics of leadership such as intelligence in leading
people. However, behavioural theory is leading others by leader's behaviour (Lussier
and Archua, 2009). Another viewpoint was shared by Al-Sawai (2013), which
discussed behavioural theory approaches that are suitable to be applied in healthcare
settings (distributive, ethical, shared and transformational). Another leadership
theories are the situational and contingency (1950–1980) which concentrate on the

significance of workers, their performed duties and the current workplace for better
accomplishment of objectives (Al-Sawai, 2013). Gopee and Galloway (2014)
emphasises on the functional type of leadership theory. They stated that the
contemporary theory has more approaches like having an appealing leader, servant
and connective as well as transactional and transformational leadership.
Accomplishment of SI needs effective leadership process which focuses on the
connected relationship between values, culture, experiences and leadership process of
organisation (Huynh and Sweeny 2013). For the purpose of this dissertation,
transformational approach of behavioural theory will be discussed in depth in the
coming section.
3.4 Leadership styles
Old (traditional) style of leadership was when the leaders took responsibility
to achieve the institutions objectives and guide his/her followers. Between 1940 and
1960, the widespread leadership styles were changed to behavioural style. As stated
by Naidoo and Wills (2015) this style focused on the behaviour of leader
(bureaucratic, democratic or laissez-fair). Leadership can be defined as influencing
the behaviour and actions of people towards achieving institution’s goals and
objectives as supported by Buchanan and Huczynski (2010), Mullins (2010), Al-
Sawai (2013), Naidoo and Wills( 2015) and Gopee and Galloway (2014). Effective
leadership is highly needed in the health care (Al-Sawai, 2013), in order to achieve
maximum quality improvement in health care settings (Kumar and Khilljee, 2015). In
this respect, successful institutions are those that develop focused solution in order to
achieve the success (Goldsmith et. al., 2010 and Barr and Dowding, 2012).
Transactional leadership is the most effective in emergency conditions such as
in emergency department. However, transformational leaders are more capable in
making the process change more effectively (Barr and Dowding, 2012); due to taking
the concern of their followers of health care above themselves. Motivating
professional involvement in the institutional vision and empowering workers led to
effective change and career succession rather than other approaches (Goldsmith et al.
2010). Transformational leaders tend to acknowledge followers and deal with
follower's success as their own success. This approach is the modern and redesigned
health care leadership style (Kumar and Khiljee, 2015). It allows health care workers
from various backgrounds to become an effective leader. However, leaders of

transactional style are considering more active as stated by Lai, (2011). Policies and
regulations are restricted to the managerial position as per this style and solving
problem taking ascending hierarchy (top to down). In addition, the acknowledgment
is based on the contract between leader and his followers after achieving specific
tasks. Whereas, transformational leadership approach uses the negotiation among
team in solving institutional issues without regard to the position of team. This style
inspires the health care workers to give their maximum efforts in order to achieve
required change and for overcoming the barriers (Bhatti et. al., 2012, Smith, 2011).
High quality care needs skilful nurses, so leadership for nursing is important in
achieving high quality care (DoH, 2008). The mechanism of management of health
workers directly affects the SI and safety (Hewison, 2010). Decentralization of
leadership in organizational management is great change were done by MoH of Oman
in 2010. However, the decision-making and communication process have become
faster and has shared responsibilities. In 2015, traditional style of transactional
leadership was brought back again in management system without any statistical
evidence which tend to centralize position (top-to down only).
According to the above discussion, importance of SI lies on appropriate
choices of leadership theory and style to organize regular training and development
sessions for SPHM. Therefore, the following discussion focuses on introducing
SPHM session for nurses in order to reduce the incidence of MS injuries in hospital
environment due to transferring and lifting patients. This process needs planned
service change and this will be by utilisation of the RAPSIES model and the
transformational leadership style.
3.5 Introducing SPHM program in local practice
Service improvement is a kind of strategic change that is implemented in the
service provision not only from patient’s viewpoint; but also through nurse’s
development point of view (Silva and et.al., 2014). SI not only changes the efficiency
of services; but also it assists nurses to enhance their capability and learning aspects
(Schilling, 2013). This has a direct impact on the health care value and in terms of
change management, it can assist nurses to amend the ratio of patient satisfaction.
Leadership capabilities need to be enhanced by the training programs. The RAPSIES
model is one of the estimation instruments that aids in accomplishing arranged change
and an effective system that counts with health care settings (Gopee and Galloway

(2014). This model consists of seven steps which are recognition, analysis,
preparation, strategies, implementation, evaluation and sustaining. The coming
discussion is focused on SI of SPHM program in Oman. As Gopee and Galloway
(2014), NHS (2015) and Houser (2015) agreed that RAPSIES model provide
structured process of assessment and analysis similar care plan process. Firstly,
describing R from RAPSIES;
Recognition
Gopee and Galloway (2014) stated that this step inperceiving the requirement
for change to set a solutions, taking care of issues and comprehend the advantages of
required change. Thus, in this context, leader (Nursing in-charge and administrative
manager) should ensure that change is convenient and applicable for his/her team with
clear aim and objective so that required change can be implemented accordingly
(Theilen and et.al., 2013). In this regard, introduction of SPHM session to staff nurses
is vital and should be mandatory based on the above discussed literature and as
increase in MSDs injuries among nurses. The need for these sessions to overcome any
future barriers regarding this change is supported by studies; Schilling, 2013,
Kneafsey, et.al., 2015, Decoyna, 2016. They conclude that there is persistent need of
availability of SPHM session for nurses in order to raise the level of practicing
handling and mobility of patients safely and effectively for both of them (patient and
nurse).
Analysis
Gopee and Galloway (2014) said that before the change can be implemented,
leader must test the options related to required change, work environment and
resources along with readiness of staff nurses to acquire change. Health care services
are effectively introduced by the nurses. At the same time, nurses are crucial in terms
of developing better relationships with the patients (McNamara, 2015). This is not
only useful in underpinning communication process; but it also changes the ways
through which services are being introduced.
As MS injuries rates increased over 52% amongst nurses, it was important to
identify the respective reasons behind this increase. It included deficiency of staff
(NIOSH, 2007), increasing work load and no transfer of tasks or activities (Nursing
World, 2010). Hence, it becomes essential for the authorities to preserve health of the
nursing staff so that there is significant reduction in patient handling injuries (Bell et

al., 2008). Furthermore, effective management and prevention programs are
developed aiming at decreasing the incidence of nurses MS injuries. As mentioned
above that there are no studies and research done in Oman to evaluate nurse’s
knowledge regarding management and prevention of MS injuries among nurses hence
these kind of initiatives are required essentially.
Preparation
At this stage, before the change is actualized, a change agent (Nurse in charge
and administrative mangers) must to be recognized who should be able to
communicate the required outcomes in an effective manner (Gopee & Galloway,
2014). A change agent should be an impetus for change that leads to create positive
required outcomes (Gopee, 2011). They must be innovative, patient listener, confident
and experts in their exact field (Nikolaou et al. 2007). A complex and vital part of a
change agent’s role is ability to deliver required messages and apply leadership skills
to ensure understanding of health care team (McNamara, 2015).
Gopee & Galloway (2014) advised using of multiple strategies to obtain
effective and efficient plan that are suitable for health care settings such as; Lewin’s
change management model (1951), empirical-rational, power-coercive , normative–
re-educative strategies and the Plan-Do-Study-Act (PDSA) cycle (Institute for
Healthcare Improvement (IHI), 2007). PDSA cycle was chosen because it provides
continuous and simple way to measure the effect of change. This cycle is essential in
terms of implementing essential transformations which are essential in the realm of
managing health care services (White, 2016). It allows for testing on a little scale and
reduces the change barriers (Gopee and Galloway 2014). Therefore, SPHM sessions
are introduced for the direct care nurses by pilot.
Implementation
Before the implementation process takes place, overview of the environment
where the change be implemented is required to prevent environmental barriers.
(Jones and Bennett 2012). Along with it, prepared and trained teams are required to
follow a well organised guideline to contribute beneficial participation and a better
sharing of experience. This demonstrates the implementation of PDSA strategy. It
mirrors the organized logical procedure of change implementation in arranged
techniques to limit expected barriers.

Plan
In this step, leaders that is the nurses in-charge are required to identify goals,
vision, objectives in order to develop appropriate action plan for the implementation
of SPHM program for direct care nurses. SPHM sessions for nurses need the
involvement of nurses, other paramedical staffs such as medical orderly and director
of nursing and health affairs for further providing their high support (MoH 2010).
Therefore, the team members will develop their action plan and sense of ownership
after getting motivated by this stage. At the same time, leader will continue his/her
role in coaching, monitoring and in continuously supporting and advising the team.
Team members will develop the sense of autonomy, since they are valued and
involved in decision making process (IHI, 2015). Then, the leader will distribute roles
and responsibilities among team members to develop their action plan regarding
implementation of SPHM program strategies. For instance, leader will distribute the
team roles over a specific period of time. In addition, leader will determine the total
number of trainees and needed trainers for the educational sessions of SPHM
program. Introducing advanced training and development SPHM sessions is required
to involve well considerate plans that will involve required resources, interested staff
nurses, funds, suitable halls, time frame, etc. This is basically in order to convince the
decision makers to support the required number of changes (McNamara, 2015). In
addition, SMART objectives for these educational sessions are helpful in setting
appropriate explanation strategy and breaking down obstacles (Naidoo and Wills
2015).
As a part of service improvement, the proposed changes regarding SPHM
program implementation need to be evaluated. It can be evaluated through formal
assessment tools such as questionnaires and tests and informally via verbal feedback.
As stated by Huber (2013), it allows the comparison of service before and after
change. Therefore, the trainers will evaluate nurse’s knowledge and awareness of
SPHM strategies. As recommended by the literatures in previous chapter, using
appropriate teaching methods is required to implement the proposed change. This can
be through education and training session (lectures with skill sessions) on SPHM
program interventions. The educational sessions should draw audience attention to the
severity of MS injuries by using valid indicators reflecting reality of problem locally
along with statistical figures of MSDs injuries prevalence among nurses and
meaningful graphs. Educational programs need preparing of educational aids such as

power point show, dolls to explain the proper method of SPHM and illustrative papers
of SPHM methods (Nursing World, 2010).
Do
In this step, the training program (lectures and teaching skills) will involve
simple, attainable, measurable, realistic and time-based objectives. The
implementation will be weekly and evaluation would be done in between two
teaching sessions. The trainers will instruct trainee to apply SPHM program
interventions. Additionally, the teaching materials should be distributed. It includes
information about SPHM program interventions and its impact on reducing the MS
injuries among staff nurses.
The leader's role will be to evaluate the progress of the program to determine
the areas of strength and weakness of SPHM program. Evaluation of SPHM program
will complete each three months after introducing the program. This will assist in
proposal modification of the program. Evaluating the performance of nursing staff
and application of safe handling and lifting techniques through proper use of
mechanical handling equipments will result in the success of this program. This will
also impact upon nurse’s health and compare the results with the responses acquired
from previously implemented program. It is hereby referred to be a helpful way to
examine the effectiveness of SPHM for nurses to overcome the barriers of change.
Later, assessment results will be shared with the higher authority (Head of Nursing
and Midwives Affarires).
Study
Any change plan will face challenges and barriers (Gopee and Galloway,
2014). So, contrasting of actual outcomes with expected outcomes reflect on their
learning experience. SWOT analysis is a powerful tool in studying Strengths,
Weaknesses, Opportunities and Threats caused either from internal or external
environmental factors (Taylor, 2007). Meeting of team members in this stage is
required to discuss these points.
This has a direct impact on health care value and in terms of change
management, it can assist the nursing leaders to amend the ratio of nursing staff who
are satisfied from the newly proposed services with corrective plans to provide the
services to the users (Silva and et. al., 2014, Houser, 2015).

Act
In this step, change maker is using the best of what has been learnt from
change and prepare action plan to get ready for the following assessment. It aims to
record what has been done, how change was carried out and the outcomes gained
(Kerridge, 2012). Required change can be done gradually with consideration of
working environment, variance in resources as well as culture and people’s readiness
to accept the new change (NHS, 2013). Formal correspondence will be distributed to
all concerned departments and fitting personnel that are selected to join new service
implementation.
Evaluating the change
It is a feedback and in order to gain an insight on how staff is coping up with
the new service and outcomes of applying new services on intended clients (Gopee
and Galloway 2014). It is a step that helps the decision maker to find out whether the
proposed outcomes have been achieved yet for further support and guidance on SI or
not (Gertler et. al., 2011). Distributing questionnaires and interviewing for nurses and
patients are helpful tools to acquire any existing barriers and planning for the future
recommendations.
Sustaining the change
It is to ensure that the change becomes a norm within practice. Gopee &
Galloway (2014) confirm that limit understanding of the change and limited support
can avoid the modification from becoming a norm. If the SPHM sessions are
introduced successfully, staff should feel that they are able to treat and support their
patients in an effective way. Ensuring consistency of changed services need persistent
programme guideline publication, establishment of a creative working environment,
cooperative teams and evidence-based knowledge that helps in introducing change
through a strategic framework (Buykx et al, 2012, NHS, 2013, Gopee and Galloway,
2014 and Naidoo and Wills 2015, and).
Barriers to implementation
The most complicated barrier of implementing change is drawing support of
higher authority (finance Support) and shortage of human resources (Gopee and
Galloway, 2014). In local Hospital, huge budget will be needed to configure the

hospital environment for the new program (room sizes, stores for handling equipage,
providing advance equipment and recruiting staff nurses).
Ethical considerations
SPHM program and other related aspects will be implemented by using the
ethical practices. Code of professional conduct should be followed because it
encourage updating knowledge and skills regularly. For example, dignity, trust and
risk reduction will be considered by the staff and management of health care sector
(ONMC, 2011). Moreover, safety of care providers and recipients is important as
recommended by the code of conduct. In addition, extensive support is provided for
nursing staff to manage their issues faced at the time of handling patients from higher
authority.
CHAPTER 4
4.1 CONCLUSION
Lifting, transferring and handling patients are the repetitive nursing activities.
It has been found that these tasks are the major cause of musculoskeletal injuries
among staff nurses. Therefore, it is essential to have skilful and competent
professional trained nurses in order to tackle this problem. As mentioned in literature,
safe patient handling mobility program is effective in reducing musculoskeletal
injuries on nurses. Literature supports the importance of introducing such preventive
program that helps in reducing musculoskeletal injuries among nurses in the early
stage and in minimising further complications as well. As stated by numerous
researchers (Gopee and Galloway 2014, Marquis and Huston 2009), effective change
management strategies along with inspiring leadership styles and proper allocation of
human and material resources are the key factors in success of change
implementation. RAPSIES model and PDSA strategies were used in explaining the
process of change introduction to local Omani Hospital. For the justification and
reasons stated earlier, transformational leadership was found to be more effective in
leading change management and more practical for service improvement. Even
though effective styles and frameworks are applied, barriers still exist because of
human nature, culture of change, working environment, organisational structure or
even the patients themselves. Because of such complexity, certain elements are to be

considered while implementing change such as where, when, how and what to change
are vital in the process success.
4.2 Recommendations
Key challenge in implementing Safe patient handling and mobility program
intervention is obtaining the approval of higher authority to establish it in the local
hospital. To achieve these, using valid indicators reflecting the reality of problem
locally, statistical figures of MSD injuries and its prevalence among nurses in
meaningful graphs and reports are needed. This dissertation recommends establishing
a safe patient handling and mobility program to limit the raise in MSD injuries among
nurses. In addition to this, a standard policy and checklist are effective in promoting
and preserving nursing health and safety. Furthermore, it is essential to develop a
national auditing tool to evaluate the effectiveness of service implementation and
ensure sustainability of appropriate handling and mobility in the clinical practice.