Home > RNJ > 2008 > January/February > Special Approaches for Safe Handling of Disabled Children in the Netherlands

Special Approaches for Safe Handling of Disabled Children in the Netherlands
Nico E. Knibbe, MSc Hanneke J. J. Knibbe, MSc RPT John Crist

This article illustrates the manner in which care providers and lawmakers in the Netherlands are addressing safe patient handling of disabled children. Standardization of ergonomic practices for safe patient handling of children requires tailored solutions at both the ward and the individual patient level. Elements such as physical contact versus device-assisted transfer, healing environment, and nonverbal (or haptonomic) communication should all be taken into account for a program to be successful. Experience from the Netherlands has shown that consideration of these factors, national guidelines, and the presence of ergocoaches can all help to ensure the success of ergonomic interventions, thereby reducing the possibility of direct caregiver injuries.

Most caregivers apply known principles of safe patient movement when they are transferring, boosting, or rolling adult patients, but they are not as likely to apply the same principles to pediatric patient movement. The aim of this article is to illustrate the manner in which care providers and lawmakers in the Netherlands are addressing safe patient handling of disabled children through

  • education about manual load limits
  • proper use of transfer devices (and consideration of impact on patient care)
  • the haptonomic approach to nonverbal communication
  • strict national guidelines on safe patient handling
  • the use of ergocoaches on inpatient wards.

This article focuses on reducing back strain, although it should be noted that good ergonomic working conditions always yield better care.

Manual Pediatric Patient Movement

Most people remember being lifted by their parents or routinely lifting their own children at home. Such recollections can make the use of a transfer device seem unnecessary and cumbersome to many caregivers working with disabled children. Also, transfer devices, slings, or batteries can be difficult to locate, and device-assisted movement can be more time consuming than manual techniques. Still, the force needed to perform manual pediatric patient movement often exceeds the U.S. National Institute for Occupational Safety and Health (NIOSH) 23- kilogram manual load handling limit (Waters & Putz-Anderson, 1991). Habitual manual patient movement of these patients puts the caregiver’s back at risk; therefore, education and an ergonomic solution are needed. In the Netherlands, readily available devices with dedicated storage areas and education on how and why to use them have helped change caregivers’ attitudes and practices.

Physical Contact and the Presence of Patient Transfer Devices

The use of devices to transfer pediatric patients can deprive a child of needed physical contact. In the Netherlands, caregivers are coached to physically comfort and touch the patient throughout any device-assisted transfer. They are trained to focus on the needs of the patient, not the device they are using.

Furthermore, the presence of a patient transfer device can disrupt the healing environment of a pediatric ward. In the Netherlands, devices on pediatric wards are painted in bright colors to make them less intimidating. Ceiling lifts are less obtrusive and may also reduce feelings of intimidation. Depending on the specific ward, a toy may be attached to the device, or the colors or logo of a popular local sports team may be printed on a sling or harness.

Ideally, each child who needs one will have an appropriately sized sling dedicated to him or her. This leads to an even distribution of the pressure on the child’s body during transfer, increasing comfort and reducing the possibility of spasms and pressure ulcers.

Custom-molded seating or bed surfaces can make it difficult to get a sling under a patient without some degree of manual lifting. Seamless lifting slings were designed to be left under a patient at all times without increasing the risk of decubitus ulcers (Figure 1).

Maximizing Patient Participation in Device-Assisted Transfers

Frequent use of lifting devices (Figure 2) can undermine a child’s opportunity for physical therapy by limiting participation in manual transfers. Manufacturers of some devices strive to incorporate patient participation in the device-assisted transfer process. The sit-to-stand (or pivot machine) is an example of a transfer device that requires some exertion on the part of the patient during the transfer. This activity can work in conjunction with a rehabilitation program. However, some pediatric patients lack the physical ability to participate in their transfers. It is possible to use extension spasms to get some of these children to participate in a pivot transfer with or without a sit-to-stand device (Knibbe, Knibbe, & Geuze, 2005).


Some pediatric patients are not able to follow basic verbal instructions; with this in mind, a nonverbal form of working with patients called haptonomics has been developed in the Netherlands. An example of a haptonomic nonverbal instruction would be to indicate the direction of movement by placing a hand on the body part the caregiver wants the patient to move. A gentle touch followed by a slow release of pressure should be used (no pushing or pulling) because very little force is needed to activate the basic neuromuscular sensors and accomplish the desired movement. Too much force may lead to reactions such as resistance or spasms.

Haptonomics also takes working space between child and caregiver into consideration. Too much space leads to uncertainty, discomfort, and fear. With too little space, the pediatric patient can hang on the caregiver. The caregiver may then give more support, increasing the passive response of the child. This leads to a tendency toward immobility and a full physical surrender to the caregiver. Ultimately, the caregiver is lifting the child completely, and the child remains passive.

Another haptonomic consideration is the speed of the caregiver’s motion in relation to the patient during a transfer. For a harmonic transfer, the speed of the caregiver and the speed of the patient should be equal. In practice, caregivers tend to dictate the speed of any transfer. This gives the patient little opportunity to cooperate and assist. In haptonomics, dancing often is used as an example of how a transfer should work. A graceful dancing couple has a shared feeling of speed, direction, and timing.

Because individual patients differ greatly in how and why they move, caregivers need to tailor the haptonomic approach to each patient (Knibbe, Knibbe, et al., 2005).

Working Environment Covenants

In the Netherlands, the ergonomic approach has been promoted through working environment covenants. These covenants are signed agreements between national parties standardizing healthcare practices in almost all sectors (e.g., pediatrics, home care, nursing homes, behavioral health, medical transportation). Employers, healthcare workers (or their unions), and government agencies work together to intervene, set goals, and produce ergonomic guidelines. The groups monitor and fund initiatives to reduce direct care-provider exposure to physical overload. These covenants were inspired by the European Committee Guidelines for promoting safe work practices and are based largely on the revised NIOSH (Waters & Putz-Anderson, 1991) lifting equation for manual lifting of loads (translated to healthcare working conditions). Examples of ergonomic healthcare standards for pediatric care set by the Dutch working environment covenants are described here.

Static Loads

Recent studies have shown that static (or postural) loads are a significant cause of back pain and injury (Janssen, Morgenstern, & Burdorf, 2004). Therefore, static loads play a central role in guidelines set by the Dutch working environment covenants. Although static overload often occurs during washing, bathing, or showering of patients (Knibbe & Knibbe, 1996), the Dutch guidelines also recommend height-adjustable surfaces for feeding, communicating, brushing a patient’s teeth, or any activity that may put the caregiver in an ergonomically compromising position (Figures 3 and 4).


Ergocoaches are an important element in implementation of the Dutch national ergonomic guidelines. One or two nurses on every ward are appointed and trained to become that ward’s ergocoaches (also called key figures, lifting coordinators, lifting specialists, or mobility coaches). These ergonomic ambassadors are available to fellow caregivers to answer questions, provide training and help with problem solving, advise on difficult or unusual patient-handling situations, and introduce new equipment and techniques. Ergocoaches work side by side with other direct caregivers on the ward. The theoretical advantage is that they are already an integral part of the group and have a comprehensive grasp of the particular experiences and problematic patient-handling situations encountered by the team. Ergocoaches must interact frequently with their colleagues, effectively demonstrating and communicating a standardized ergonomic approach. The ergocoach in the Netherlands is similar to a peer opinion leader (Nelson, 2006; Thompson, Estabrooks, & Degner, 2006).

Although no available research directly supports or quantifies the effectiveness of the ergocoach program, some intriguing results may guide further research. For example, facilities that have implemented both ergocoaches and the Dutch national ergonomic guidelines have shown a lower incidence of caregiver sick leave than facilities that have not yet fully implemented the guidelines (Knibbe, Panhuys, & Vugt, 2005). This finding may indicate that ergocoaches are not necessarily effective as stand-alone interventions but can positively influence the implementation of guidelines and standardized ergonomic practices. Existing quantifiable results make more in-depth research necessary and relevant. Research of this type may also shed more light on the implementation of ergonomic interventions in complex facilities that treat pediatric patients. This research is currently being undertaken by the Erasmus University Rotterdam, in close cooperation with LOCOmotion.

Nursing Implications

  • Although the total weight of a child may be small, caregiver exertion can still easily exceed guidelines for safe manual handling; therefore, safe patient-handling devices may be needed.
  • Because the presence and use of patient transfer devices can disrupt the healing environment of a pediatric ward, special attention must be paid to the way the device fits into the environment and the physical comfort and security of the patient throughout any device-assisted transfer.
  • The use of seamless slings (particularly with patients using custom-molded sleep or seating surfaces) makes device-assisted transfers safer, while reducing the likelihood of decubitus ulcers in patients who lie on them.
  • The concept of haptonomics is a thoroughly developed nonverbal form of working with pediatric patients. Its use improves the cooperation between the caregiver and the patient, reduces the physical load on the caregiver, and increases the patient’s mobility.
  • Static or postural load is a serious but underestimated cause of musculoskeletal injuries in the nursing profession. Height-adjustable baths, beds (Figure 5), shower trolleys, and stools should be used for patient care.
  • Ergocoaches (peer opinion leaders) can help to initiate and ensure the success of ergonomic interventions.

About the Authors

Nico E. Knibbe, MSc, is a research associate with LOCO motion Research and Health Consultancy in Bennekom, the Netherlands. Address correspondence to him at n.e.knibbe@locomotion.nu.

Hanneke J. J. Knibbe, MSc RPT, is a research associate with LOCOmotion Research and Health Consultancy in Bennekom, the Netherlands.

John Crist supervises inpatient transport services at Abbott Northwestern Hospital, Minneapolis, MN.


Janssen, J. P., Morgenstern, H., & Burdorf, A. (2004). Dose response relations between occupational exposures to physical and psychosocial factors and the risk of low back pain. Occupational Environmental Medicine, 61, 972–979.

Knibbe, N. E., & Knibbe, J. J. (1996, November). Postural load and efficiency of bathing and showering. Results of a laboratory study. Professional Safety, pp. 37–39.

Knibbe, J. J., Knibbe, N. E., & Geuze, L. (2005). ErgoCoaches in Beeld. Bennekom, The Netherlands: LOCOmotion.

Knibbe, H., Panhuys, W. van, & Vugt, W. van. (2005). Handbook of transfers. Amsterdam: Corpus.

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Thompson, G. N., Estabrooks, C. A., & Degner, L. F. (2006). Clarifying the concepts in knowledge transfer: A literature review. Journal of Advanced Nursing, 53(6), 691–701.

Waters, T. R., & Putz-Anderson, V. (1991). Scientific support documentation for the revised 1991 NIOSH lifting equation. Technical Contract Reports. Washington, DC: National Institute for Occupational Safety and Health.