Studying feasibility and effects of a two-stage nursing staff training in residential geriatric care using a 30 month mixed-methods design [ISRCTN24344776]

Kinaesthetics is a care concept for human movement, which describes and analyses the fundamental nature of human movement with regard to self-control, functioning and health development. The theoretical bases are to be found in behavioural cybernetics, human psychology and various directions and styles of modern dance [10]. The founders of Kinaesthetics are Dr. L. Maietta and Dr. F. Hatch, USA, who first used Kinaesthetics with students who were interested in their own movement skills. The core of Kinaesthetics is the communication and interaction between humans which is carried out while moving [10]. This human interaction is considered under six concepts; interaction, functional anatomy, human movement, human functions, effort expended as a means of communication, and the environment. The sub-themes of the concepts allow a deeper analysis into different aspects of movement. Each of these concepts is present in every interaction and they can be used for a systematic analysis of human movement resources (Table 1) [10].

The purpose of Kinaesthetics training is to give nurses the fundamental understanding of natural human movement and of its meaning with regard to human existence, perception of one's own body, environment and functioning in daily life. Through this understanding the nurses should develop their own movement competences.

Movement competence is defined as the ability to use one's own movement for solving motor, cognitive or social challenges with motion and to create optimal situations [9]. Ideally, it uses all of the internal and external resources for motor situations in daily life such as in their job and leisure time. Internal resources are the motor abilities and skills, e.g. physical condition, coordination, cognition and constitution. External resources are the potential of the environment such as devices or the social environment [11]. Nurses are more able to work in a resource-orientated manner, to perform different resident movement tasks with ease, to support the patient's active participation towards their own locomotion and to increase the patient's perceptions of their own body and environment. The methods of teaching are interpersonal and interactive.

In Kinaesthetics courses, nurses learn first to understand each concept in their own body. They learn to recognise what happens in their own body while moving themselves. This is a precondition for their understanding of the movement of other people. Secondly, they learn to move other people by using their experiences of each concept. Thirdly, they use Kinaesthetics concepts in different patient situations. The workbook is used to support the cognitive learning.

There are only few studies of the effects of Kinaesthetics on the nursing staff. One study in Finland investigated the impact of Kinaesthetics on the physical strain of the nurses in one health care centre taking care of elderly surgical and medical patients [12]. The aim of this study was to show the change in the physical strain on back and shoulder muscles in 12 nurses who swapped the usual transfer technique for the new method, Durewall^® (a transfer technique from Sweden) and Kinaesthetics 83 transfers (bed-wheelchair/wheelchair-bed) were videotaped (25 before training, 28 after the first training and 30 after the second training). During the transfers, the nurses' activity of m. trapezius and m. erector spinae were measured on both sides with a portable EMG.

Furthermore, experts in Kinaesthetics evaluated the nurses' individual performance and learning in patient transfer tasks and the patient participation in locomotion activities from the videotapes. For this purpose a newly developed instrument, SOPMAS (Structure of The Observed Patient Movement Assistance Skill) was used. It covers the following ergonomic and Kinaesthetics items: interaction, patient's movement, nurse's posture and movements as well as environment and auxiliary devices. The rating scale ranged from 1 = no skills to 5 = very good skills.

The results indicated, that the nurses could develop their own movement competence and that the mobilisation with Durewall^® or Kinaesthetics reduced the physical load by 50%. The EMG results correlated significantly with the SOPMAS results, which means, that a higher SOPMAS score signifies a decline in physical strain [12].

In a prospective, descriptive comparative study, Burns and Sailer investigated whether Kinaesthetics can positively influence the discomfort in neck and lumbar spine by nurses in a neurological clinic [13]. In the intervention group there were 65 nurses from 6 wards. In the control group there were 60 nurses from 6 wards. The answers from the questionnaire showed that the intervention group which was trained in Kinaesthetics had less back pain than the control group. These results indicate that training in Kinaesthetics could reduce the back pain in nursing staff.

In the study of Tamminen-Peter (2005) patients were asked for their safety, control and comfort during the mobilisation with a bipolar scale from -4 to +4. All of these three quality indicators were found to be significantly better by the mobilisation with the new methods (Durewall and Kinaesthetics) [12].

One case study examined if a movement support based on Kinaesthetics furthers the development and improvement of body awareness, movement abilities and functional independence of elderly nursing home residents [14]. Two elderly nursing home residents, who showed a strong dependence (Barthel index II; 20-60 points) after a stroke, demonstrated a clear improvement in information understanding, body perception, and movement abilities. Functional independence measured by Barthel index increased in case A from 30 to 40 points and, case B from 55 to 95 points. The results indicate that movement support based on the principles of Kinaesthetics, if used consistently, continuously and in a manner adapted to the situation of the person requiring assistance, could increase the body perception, movement abilities, and the functional independence of patients of advanced age.

Burns and Sailer studied patient's independence in the activity of daily-life movement and how the patients experienced the concept of Kinaesthetics [13]. Twelve patients were interviewed in a semi-structured interview. The result was that the patient experienced a higher feeling of safety and independence. It is not clear, however, if it was the concept of Kinaesthetics or the greater attention of the nurses which influenced the results with regard to increased feeling of safety and greater independence on the part of the patients. One further limitation was the fact that the nurses were not all equally adept in the use of the concept of Kinaesthetics.

On the whole, health care organisations are investing heavily in staff training in Kinaesthetics and the experience from clinical practice is very positive. Nevertheless, we have a lack of research evidence of the effectiveness of Kinaesthetics training for nursing staff and patients.

At T2, residents as well as staff will be asked if they once more would take part in the study. Using the percentage of negative replies and the drop-out rate, feasibility criteria RES_1 and RES_2 can be calculated. RES_3 (missing values) will be calculated after data processing.

Immediately after each transfer recorded at T0, T1 and T2, the residents will be asked about the safety, comfort, pain and one's own participation during the transfer with a questionnaire. The scale ranges for pain from 0 = no pain to 5 = unbearable pain; for safety from 0 = very unsafe to 5 = very safe; for comfort from 0 = very uncomfortable to 5 = very comfortable and for participation from 1 = very low participation to 5 = very high participation. The feasibility criteria SCI_1 and SCI_2 will be calculated after data processing.

Immediately after every transfer recorded at T0, T1 and T2 the nurses will be asked about the subjectively perceived physical strain during patient transfer. The data will be collected with the Borg CR10 scale of perceived strain, with a scale from 0 = no strain at all to 10 = extreme strain after every patient transfer (SCI_4) [21].

The movement competence of the nurses will be measured with the SOPMAS Instrument (Structure of the Observed Patient Movement Assistance Skill) (SCI_5). It observes each nurse's individual performance and learning in patient transfer tasks and patient participation in locomotion activities with 4 items: interaction, patient's movement, the nurse's posture and movement, environment and auxiliary devices. The scale ranges from 1 = no skills to 5 = very good skills. All scale levels were given specific definitions, suited for patient transfer situations. The instrument was tested and compared with the Swedish DINO instrument [22] of which validity and reliability have been tested. The correlation was tested by the Pearson test and was good (r = 0.72), though there was a level difference. The highest level of the SOPMAS was missing in the DINO [12]. Video recordings of two transfers of each nurse, e.g. bed-wheelchair/chair-bed, transfer in bed (positioning) will be recorded at the measurement points at the baseline before training (T0), within one month after the basic course (T1) and within one month after the advanced course (T2). The feasibility criteria SCI_3 of the residents for the Item patient's movement and the score over all items SCI_5 for the nurses will be calculated after data processing.

The reasons of residents and staff leaving the programme will be discriminated. Adverse events (AE) are considered in the process-oriented feasibility. Therefore, the whole number of drop-outs will be diminished by the drop-outs due to AE. Leaving the programme on one's own decision should be 50% or less for the residents (PRO_1), and 30% or less for the nurses (PRO_2).