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ENROLLED NURSE

ENROLLED NURSE Human factors Reaching:

Frequent forward reaching, neck flexion, occasional overhead reaching.

Heights:

Ground to overhead.

Controls and displays:

Dressings, medication distribution, making beds, paperwork.

Force exertion/lift:

Five kg medication trays and treatment trays.

Postural requirements:

Frequent standing and walking, bending, kneeling, crouching

Overall physical demand level:

Medium

Work/rest patterns:

Eight-hour rotating shifts, five days a week

Frequency of resident and/or equipment handling:

Frequent for resident transfer, wound care, treatments, medications and observations.

Handling and fingering requirements:

Frequent

Tools:

Dressing trolley, drugs trolley, operating bath lifter and mechanical hoist.

Size of article:

Variable.

Protective clothing:

Standard uniform.

NOTE: Unsuitable for workers with walking/getting up and down from the floor restrictions.

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JOB ANALYSIS

Occupation: Enrolled Nurse Task description There are two main areas in which Enrolled Nurse’s may be rostered, depending on the aged care facility. The facility may be predominately low care area, or high care area, or, with aging in place with residents of varying needs spread throughout the facility. At the facility there may also be low or high care dementia specific areas. Hours of work: Day, Afternoon or Night Shifts. Roster and hours of work vary according to the requirements and staffing of the facility. As a guide: Day Shift: 7am – 3.00pm, Afternoon Shift: 3pm to 11pm, Night Shift 11pm to 7am. Task Description: Low Care Area, Day Shift The Enrolled Nurse works in a team including a Registered Nurse and Care Workers to assist with activities of daily living, medication distribution, dressings, and care for residents who are mainly mobile and require light physical assistance. The Enrolled nurse is responsible for two medication rounds; which may be undertaken predominately in the dining room. There may be one or two residents who require medication distribution in their rooms. A lunchtime medication round may also be undertaken in the dining room. The Enrolled Nurse is also responsible for undertaking any wound dressings on residents, BSL levels, blood pressure monitoring, observations, administration of inhalant medications, treatment and administration of eye medications, and clinical observations. Enrolled Nurses also assist with resident transfers when Care Workers require assistance. While Care Workers predominantly undertake the resident transfers; the Enrolled nurse is also expected to assist. Resident transfers are such as: bed based transfers, sit to stand transfers and lifter transfers. Enrolled Nurses also assist with putting clothing on and off residents; but at a lesser volume than Care Workers. Documentation is also undertaken; and they also assist the Registered Nurses with the Doctor’s rounds, audits and looking at quality indicators. Enrolled Nurses supervise Care Workers, and assist other staff with tasks as required. Critical physical demands: • Frequent standing and walking • Occasional sitting • Frequent stooping, crouching, lunging • Occasional kneeling • Frequent forward reaching to 60 degrees • Occasional over head reaching • Occasional forward reaching to 90 degrees • Frequent strong pincer grip for medication distribution • Frequent neck flexion • Frequent handling, palmar grasp with either hand against resistance

PHYSICAL DEMAND LEVEL: MEDIUM Tools used: Mortar and pestle, medication trolley, Webster pack® containing medication, dressing requirements, lifters, slide sheets, protective clothing, closed-in shoes, masks if necessary for specific dressings and for infection control.

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ENROLLED NURSE

ENROLLED NURSE Physical Demands Factors

Sitting Comments Standing

Never

Occasional

Frequent

Constant

0% of day

1-33% of day

34-66% of day

67-100% of day

5

5

5

Documentation

Comments Walking

Comments

Stooping

Comments

Crouching Comments Kneeling Comments Climbing

Medication distribution, assisting carers and other staff with activities of daily living requirements for residents, assisting to manoeuvre residents in wheel chairs to appointments within the complex. Assisting residents with walking □

5

To access the lower drawers of a medication trolley, to access the lower shelf of a dressing trolley, when performing dressings on residents’ legs when residents are seated, or if residents are lying on a low fixed height bed. □

5

As above, plus assisting with resident transfers, sit to stand, lie to sit □

5

Very low dressing, i.e. assisting to place resident shoes and socks on 5

5

Comments Forward reaching Comments Overhead reaching Comments Handling and fingering

Comments

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Personal care, transfers, showering, wound care and treatments □

5

5

Clothes in wardrobes □

Use of mortar & pestle, medications, Webster pack ®, dressing items. BSL machines. Blood pressure machines. Dentures, hearing aids, spectacles. Pens, keyboard operation. Push/pull of equipment.

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ENROLLED NURSE

ENROLLED NURSE Physical Demands Factors

Occasional

Frequent

Constant

1-33% of day

34-66% of day

67-100% of day

Bench height lift

5

Bench height: • lifting of medication book: weight to 4kg • medication from top two drawers of a medication trolley: weight less than 1kg • dressing tray or treatment items: weight less than 2kg Floor to bench: Comments

• accessing drawers below waist height • assisting residents who are seated at a table with eating and drinking. • assisting a resident with a sit to stand transfer with another staff member Bench to shoulder: • accessing files, stationery • medication cupboards

Overhead lift

5□

Comments Push

Comments

Medication trolley: rolling resistance up to 12kg, dressing trolley: rolling resistance less than 5kg, oxygen cylinder on trolley: rolling resistance 5kg, blood pressure monitor: rolling resistance less than 2kg, resident in a wheel chair: rolling resistance up to 15kg, manoeuvring a lifter with a resident in position: rolling resistance up to 15kg.

Pull Comments

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5

5

As above

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ENROLLED NURSE

TASK ANALYSIS 1. MEDICATION ADMINISTRATION AND REVIEW This task may require the Enrolled Nurse to lift medication tray (< 5kg) from shoulder height depending on storage arrangements and place onto the medication trolley. The rolling resistance force to push the trolley varies (photograph 1). It has been measured as up to 12kg depending on the surface traversed and the placement of the trolley wheels.

Photo 1

Photo 2

The lowest drawer of the trolley should be accessed by kneeling or crouching to avoid stooping. Drugs should be administered to residents by kneeling or crouching as well, to avoid stooping. Photos (photographs 2, 3 & 4) show the posture and handgrips required for medication administration.

Photo 3

Photo 4

2. WOUND TREATMENT The dressing trolley is manoeuvred from room to room, where Enrolled Nurses may have to wind up the beds in order to prepare the residents for treatment. It is important that the enrolled nurse is positioned correctly. Independent residents are assisted to walk by the Enrolled Nurse if the treatment is to be done in the residentâ&#x20AC;&#x2122;s room. The Enrolled Nurse may also have to push a resident in a wheelchair Some wound care is carried out with the resident sitting, requiring the Enrolled Nurse to squat or kneel (photograph 5 & 6). A stool may be used by the Enrolled Nurse to perform the wound care tasks. Refer to Table 13 reflecting average rolling resistance for people in chairs, wheelchairs and lifters over different floor surfaces on page 103 at the end of this chapter.

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Photo 5

Photo 6

3. DOCUMENTATION When completing paperwork related to the administration of medication, Enrolled Nurses may have to access files at different heights depending on the storage set-up (photograph 7). Enrolled Nurses may have to reach overhead to lift down folders of < 5kg (photograph 8). A safety step, or a two tiered stepladder with handle, should be made available to access files at/above shoulder height.

Photo 7

Photo 8

4. CLINICAL ASSESSMENT This task involves resident clinical observations; including wound status, and following treatment orders.

5. LIAISON WITH OTHER HEALTH PROFESSIONALS, STAFF, RESIDENTS AND FAMILIES This task requires the Enrolled Nurse to supervise care staff and conduct meetings with staff, liaise with doctors and other health professionals necessitating frequent changes in posture.

6. MANUAL HANDLING The Enrolled Nurse is required to demonstrate the capacity to constantly bend, lunge crouch and reach to access all body parts when assisting a resident in personal care and to conduct treatments. The Enrolled Nurse may have a practical role in reinforcing manual handling concepts and act as a role model for other staff (photographs 9 & 10).

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Photo 9

Photo 10

Manual handling of residents is a task required of Enrolled Nurses. The Enrolled Nurse must be able to understand and demonstrate competency in manual handling techniques used to move residents (photographs 11 - 14). Further details of specific manual handling requirements in ‘bed making’ and ‘personal care of residents’ follow in sections 8 and 9; manual handling requirements for ‘wound treatment’ are as described in section 2.

Photo 11

Photo 13

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Photo 12

Photo 14

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7. COMMITTEE MEETINGS This task involves quality assurance and resident status and Resident Classification Scale (RCS) documentation as per the aged care facility requirements. This could involve prolonged sitting up to an hour, and note taking.

8. BED MAKING Beds are raised to waist height prior to making the bed to avoid spinal stooping. After making, the beds are lowered to the correct height for the resident’s comfort. If the beds are not electric, the Enrolled Nurse frequently winds the beds. To reduce the load on the spine and upper limbs it is advisable to use a half-kneel or semi-squat technique. The Enrolled Nurse is advised to place himself or herself side-on to the bed (photograph 15).

Photo 15 Bed making may consist of pulling up the bedclothes or a full strip and re-make with clean linen (photograph 16). The resident must be able to take at least a few small steps for the following technique to be used. Before making the bed, the Enrolled Nurse and a Carer Worker will assist the resident into a sitting position, by sitting them up through side lying or raising the bed to a sitting position, to avoid lifting the weight of the upper torso (photograph 17). The resident’s legs are then brought around and onto the floor and the Enrolled Nurse and the Care Worker transfer the resident from sitting to standing. The resident is then lowered into a chair.

Photo 16

Photo 17

9. PERSONAL CARE OF RESIDENTS The Enrolled Nurse may also assist the Care Workers to perform duties, which include transferring residents in and out of their beds or to reposition the resident in the bed using a ‘Slippery Sam’ or ‘slide sheet’. (photographs 18 & 19).

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ENROLLED NURSE The Enrolled Nurse and Care Worker must assume semi-squat (bend at the hips and knees) or lunge positions and pull-through with the whole body to ensure minimal load is placed through the spine and upper limbs. The care workers’ elbows should be aimed in towards their bodies. Refer to Table 11: ‘Patient Transfer Forces’ on page 101 at the end of this chapter.

Photo 18

Photo 19

Details documenting methods for dressing Residents are in ‘Care Worker – Residential’, Section 8 ‘Attending to residents’. A mechanical lifter is used to lift residents out of bed (photograph 20). The Enrolled Nurse and the Care Worker could lift up to 20kg each using this method of lifting if the resident is not in a position to assist. In some facilities an overhead ceiling hoist is installed. It is recommended that when lifting a resident using the lifter, the Enrolled Nurse and the Care Worker roll the resident (photograph 21) to prevent lifting the weight of the upper torso. The Enrolled Nurse should use a wide stance (at least shoulder width apart), and bend at the hips and knees, maintaining the normal curve of the spine.

Photo 20

Photo 21

The Enrolled Nurse guides the resident in the lifter while the Care Worker pulls the lifter out from the bed (photograph 22). This can be difficult to do in a restricted space. If the resident can’t reliably weight bear, a lifter or hoist is used. When removing the lifter straps from the resident and positioning the wheelchair/shower chair footplates, the Enrolled Nurse should crouch rather than stoop.

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ENROLLED NURSE The shower chair (photograph 23) requires a pushing force of 9kg when the resident weighs 87kg. The Enrolled Nurse assists the resident with washing in the shower. For details of Push/Pull Forces of equipment, with and without residents refer to Table 13 on page 103 at the end of this chapter.

Photo 22

Photo 23

There are bathing facilities at some sites. The Enrolled Nurse may assist with this task. The bath lifter is operated manually by winding a handle. The handle is released to lower the resident into the bath (photographs 24 & 25).

Photo 24

Photo 25

If a resident is reliably able to bear weight to mobilise, only one care worker is required to assist (sometimes with verbal prompting only), while the resident performs the manoeuvre of standing (using a frame) from a sitting position (photograph 26). Some light assistance may be required, in the form of guidance, to encourage the resident to lean forward and stand while holding onto the walking frame. An Enrolled Nurse and a Care Worker may assist a resident to stand and walk if the resident is able to reliably weight bear to mobilise. The Enrolled Nurse may be required to give assistance due to reduced balance or cognitive problems. Spinal stooping should be avoided by the adoption of a lunge position, bending at the hips and knees. The resident should be assisted to lean forwards then stand. Once stable in standing, the resident may require light assistance to mobilize (photograph 27).

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Photo 26

Photo 27

10. MAKING UP STAFF ROSTERS WITH CLINICAL NURSE CONSULTANT This task requires the Enrolled Nurse to sit at the VDU computer workstation, getting up occasionally to access files. This gives the Enrolled Nurse the opportunity to interchange between postures on a regular basis (photograph 28). Accessing files may require stooping or overhead reaching to lift down a folder (< 5kg), depending on the storage system at each site.

Photo 28

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TABLE 11: PATIENT TRANSFERS – FORCES ACTIVITY

PATIENT WEIGHT 60 KG

80 KG

100 KG

17.8

28.9

35.3

HEAVY - 100% OF SIT FORWARD

17.8

28.9

35.3

LIGHT – 60% OF SIT FORWARD

10.7

17.3

21.2

1- ROLL

8.7

16.5

27.9

2- PULL BOTTOM THROUGH

28.5

42.4

53.5

LIFT LEGS

8.5

15.2

16.3

SLIDE UP BED

60 KG

80 KG

100 KG

120 KG

1 slide sheet (doubled)

9.9

14.8

20.1

N/A

18.9

24

32.2

N/A

14

20.4

24.9

28

16.9

14.5

16.4

20.4

SIT PATIENT FORWARD Min. head control

SIT ON EDGE OF BED

ROLL ONTO SIDE (no slide sheet)

SLIDE SHEETS

Patient’s knees bent 1 slide sheet (doubled) Patient’s legs straight 2 slide sheets Patient’s legs straight

ROLLING 1 slide sheet doubled. Knee bent, arm reach, head turned Reference: ‘Patient transfers – forces’: Paul Rothmore, Senior Physiotherapist / Ergonomist, Repatriation General Hospital, and Gillian Elix, Ergonomist, Flinders Medical Centre, 2004

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TABLE 12: PUSH / PULL FORCES OF EQUIPMENT EQUIPMENT Small Tea Trolley Tea Trolley Kitchen Trolley

EMPTY

EMPTY

WITH LOAD

WITH LOAD

- PUSH

- PULL

- PUSH

- PULL

2 kg

3 kg

-

-

6 kg

6 kg

-

-

5 kg

6 kg

(¾ full)

(¾ full)

6 kg

6 kg

Linen Trolley Dressing Trolley Medication Trolley

-

-

4 kg

4 kg

-

-

8 kg

6 kg

Reference: Mary Hill, Safe Work Practice, Clinical Application, 2005. Forces were measured using a ‘Baseline’ hydraulic push/pull dynamometer.

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TABLE 13: PUSH / PULL FORCES OF EQUIPMENT EQUIPMENT

Wheelchair (standard): -empty; light resident Wheelchair: -heavier resident Shower chair:

EMPTY

EMPTY

WITH LOAD

WITH LOAD

PUSH

PULL

PUSH

PULL

4 kg

4 kg

(52 kg Res)

(52 kg Res)

6 kg

5 kg

-

-

(79kg Res)

(79kg Res)

7 kg

7 kg

3 kg

3 kg

(72 kg Res)

(72 kg Res)

13 – 15 kg

10 –12 kg

(72 kg Res)

(72 kg Res)

9 - 10 kg

10 –12 kg

-flat carpeted surface Shower chair:

2 kg

2 kg

-lino/bathroom floor -empty; heavier resident

Note: ‘shower chair with load’, the range refers to residents feet being off, and then on, the pull-out footplate Princess chair:

5 kg

5 kg

(12 cm wheels)

(59 kg Res)

(59 kg Res)

10 kg

8 kg

(70 kg Res)

(70 kg Res)

12 kg

9 kg

(74 kg Res)

(74 kg Res)

10 kg

8 kg

-

-

(72 kg Res)

(72 kg Res)

17 kg

13 – 15 kg

(72kg Res)

(72kg Res)

13 kg

14 kg

4 kg

5 kg

(72 kg Res)

(72 kg Res)

13 – 15 kg

20 - 22 kg

-empty; light resident Princess chair:

-

-

-heavier resident

King chair:

-

-

5 kg

4 kg

-

-

6 kg

6 kg

Bed side cupboard

-

-

Beds

10 kg

16 kg

(20cm wheels) Q foams: -empty Q foams: -heavier resident Lifter -flat carpeted surface

NB: Res. = Resident Reference: Mary Hill, Safe Work Practice, Clinical Application, 2005. Forces were measured using a ‘Baseline’ hydraulic push/pull dynamometer.

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Rehabilitation of injured Enrolled Nurses Proposed duties Time spent per day

01%-33%

34%-66%

67%-100%

Rehab

Rehab

Rehab

Plan 1

Plan 2

Plan 3

Preparing documentation Forward reaching

Sitting

Communicating with residents/family members Standing

Wound management Crouching

Fingering

Handling

Forward reaching Kneeling

● ●

Standing Stooping

● ●

Personal care Handling

Forward reaching

Standing

Walking

Making beds Crouching

Forward reaching Kneeling

Stooping

Walking

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Booklet 3 patients rights