When preparing to transfer a patient from their bed to a wheelchair What is the first step?

This third of a five-part series on early mobilisation provides a step-by-step guide to supporting patient transfers from bed to chair

Abstract

Patients in hospital with reduced mobility may experience difficulty moving in and out of bed, even if they report being relatively independent before admission. Part 2 of this five-part series explained how to assess the patient and formulate a mobilisation care plan; this article shows how to guide and support patients’ transfer from bed to chair without aids, as a common first step in their early mobilisation.

Citation: Rindsland S (2021) Early mobilisation 3: moving patients from their bed to chair without aids. Nursing Times [online]; 117: 6, 42-44.

Author: Sharon Rindsland is moving and handling senior coordinator, East Kent Hospitals University Foundation NHS Trust.

• This article has been double-blind peer reviewed
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• This article is funded by an unrestricted educational grant from Hillrom

Patients should be encouraged to sit in a chair or wheelchair whenever possible to “prevent chest infections, normalise blood pressure, allow the bodyweight to be distributed evenly over both hips and thighs, and increase their sitting tolerance and stamina” (Lister et al, 2020). Lister et al (2020) note that this is important for psychological wellbeing, as it encourages patients to socialise and participate in their surroundings. This article describes the steps in guiding a patient transfer from lying in bed to sitting in a chair; it assumes the patient has minimal or low handling risk but needs assistance from one member of staff.

To perform this manoeuvre, patients should be clinically stable and able to:

• Initiate their own movement;
• Understand and follow instructions;
• Lean forward;
• Balance while sitting;
• Balance while standing;
• Take steps sideways and backwards, as well as forwards;
• Bear their own weight.

Before undertaking any procedure, staff should be aware of their own and their employer’s responsibilities to ensure safer moving and handling of patients; these are outlined in Box 1.

Box 1. Safer patient handling

Employer responsibilities include:

• Having safer patient handling policies and risk management processes in place, along with arrangements to monitor staff compliance
• Giving staff access to the appropriate equipment to undertake their role safely and ensuring equipment is well maintained
• Providing staff with regular training in safe moving and handling, and equipment use

Employee responsibilities include:

• Regularly assessing patients’ handling and mobility needs
• Following appropriate systems of work and attending training
• Avoiding manual handling for tasks that could cause injury and using the equipment provided
• Informing employers of any problems

Sources: Bit.ly/HSEMoveHandling; Bit.ly/RCNMoveHandling

Caregivers need to be wearing appropriate non-slip regulation footwear and appropriate uniform/clothing, and must ensure any sharp objects, such as scissors, are securely stored, so they do not cause injury. They need to follow safe manual-handling procedures (Smith, 2013; Bit.ly/HSEPushPull) and adopt a safe posture at all times (Box 2).

Box 2. Handling tips

Caregiver safety

• Position yourself as close as possible to the person you are helping
• Remember to use your leg muscles, not your back muscles, to lift
• Always bend your knees and keep your back straight
• Avoid sideways bending or twisting your back

Patient safety

• Follow any precautions documented in the patient’s care plan
• Never force or pull on the patient’s limb
• Help patients on their weaker side if they have one
• Avoid shearing and friction forces on the skin, particularly for older people
• Follow local policies and procedures at all times and seek advice if you are unsure about how to safely move a patient

Sources: Vatwani (2017); Bit.ly/HSEMHOR

Understand the patient

Before undertaking any procedure, care-givers should read the assessment/care plan to understand the patient’s mobility needs/goals, communication needs, preferences and any factors that might affect their ability to mobilise (Rindsland, 2021). This includes checking that the patient’s mobility assessment is up to date and there are no changes that require review, such as a change in medication – as an example, opioids can cause drowsiness, slow reactions and impair balance.

Patients’ needs change, and safe mobilisation is about that individual’s mobility needs at that specific point in time; as such, although the assessment and standard procedures are a good guide, you need to listen to the patient and watch for changes in their ability. This will help you to decide whether they are ready for the next move or need extra assistance; for example, if a patient feels dizzy when coming to a sitting position at the side of the bed, they are likely to need to be reviewed. If at any stage the patient appears to be in discomfort or pain, consider stopping and reviewing analgesia before carrying out the procedure.

Infection prevention and control

Non-sterile gloves are not required routinely for moving and handling procedures. Nurses need to assess individual patients for the risk of exposure to blood and body fluids (Royal College of Nursing, 2020) and to be aware of local policies for glove use.

Preparing for transfer

Introduce yourself, ensuring the patient is wearing glasses or hearing aids if required. Explain the procedure and what the patient is expected to do and gain their consent. Ask the patient if they have any preferences and try to accommodate them as far as possible, while explaining the need to follow safe procedures. Remember that in some cultures and religions, touching – such as physical contact between males and females – may be considered inappropriate, so you may need to look for solutions or compromises. If the patient has special communication needs, such as a hearing or cognitive impairment or language difficulties, you may need to demonstrate the move with another person or consider the use of an interpreter.

Preserving patients’ dignity is important and encouraging them to get dressed when out of bed can improve their motivation and psychological wellbeing (Stephenson, 2018; Walker et al, 2018). If this is not possible, ensure the patient is adequately clothed and will not be exposed during the procedure; provide screening if it is needed.

When helping a patient to transfer from bed to chair, it is important to ensure they are wearing secure, non-slip footwear – ill-fitting or backless footwear and novelty slippers can be a falls risk. If appropriate footwear is not available, bare feet are preferable to socks or stockings, which may slip (Lister et al, 2020).

Procedure

1. Decontaminate your hands and apply personal protective equipment if required.

2. Decide which side of the bed the patient should get out from based on their strength, comfort, ease of transfer and the side they normally use. If the patient has weakness on one side, for example following a stroke, the chair should be placed on the unaffected side.

3. Provide an upright chair with arms. Check it has been cleaned and position the chair next to the bed – make sure the area around it is safe and clear, and there is plenty of space for you to turn with the patient.

4. If the patient uses a walking aid, this should be ready for use, so they can take hold of it once they are standing.

5. Ensure any equipment, such as cardiac monitor leads or intravenous infusions, have enough slack and will not interfere with the transfer. Depending on the patient’s condition, it may be possible to disconnect some equipment temporarily to facilitate transfer.

6. Adjust the bed to a safe height, as indicated by the patient’s assessment (Smith, 2013). Always stay close to the patient.

7. If you have someone to help you, one person should take responsibility for coordinating the transfer.

8. Agree with the patient and/or colleague some clear prompts beforehand, such as “ready, steady, stand”, so the patient can move with confidence, knowing what they need to do. Talk to the patient and reassure them at every stage.

From lying to side-sitting on the bed

Encourage the patient to roll onto their side by:

9. Bending both knees upwards from a lying position, or bending the knee that is farthest from the direction of the roll (Lister et al, 2020) (Fig 1a).

10. Turning their head in the direction they are moving and reaching towards the same side of the bed with their uppermost arm, while moving the other arm away from the body to avoid it becoming trapped.

11. Allowing their flexed knees/outer knee to fall onto the bed in the direction of the roll, so their body weight takes them onto their side (Fig 1b). To guide the patient into a sitting position, stand close to the bed, facing them and with your feet apart (Smith, 2013) and then:

12. Place one hand on the patient’s shoulder and the other on their hip. Do not grip or lift the patient (Smith, 2013).

13. Ask the patient to slide their bent legs over the side of the bed, while raising their head and pushing up, using their outside hand and elbow of their inside arm (Fig 1c). If the patient is in a profiling bed, raise the backrest to help them, following the manufacturer’s operating instructions.

14. Guide the patient so they are in an upright sitting position with their feet firmly on the floor (Smith, 2013).

15. Monitor any pain or dizziness as the patient sits up as this could indicate postural hypotension or vertigo (Lister et al, 2020). If this occurs, return the patient to a lying position and reassess.

From sitting to standing

Ensure the patient is wearing appropriate footwear and that, if they require a walking aid, it is positioned ready for use. For a patient who needs minimal assistance, position yourself as follows:

16. Stand at right angles to the bed next to the patient, with your feet apart and knees relaxed.

17. Place your hand that is nearest to the patient at a comfortable distance at the base of their spine (Fig 2a). Do not grasp their clothing or belt – the hand is a touch prompt to stand and it is important not to push the patient (Smith, 2013).

18. Place your other hand on, or just in front of, the patient’s shoulder that is nearest to you (but never under their armpit) (Fig 2b).

19. In this position you can guide the patient to push themself up, depending on their assessment and following safe handling procedures.

Once you are in position, instruct the patient to:

20. Lean forward and transfer their weight from side to side, so they shuffle to the edge of the bed.

21. Move their feet back until they are tucked under the bed slightly, hip width apart; the patient’s knees should be slightly over their toes, so they do not lose their balance when standing.

22. Ask the patient to place their hands on the bed or on their thighs, and then to lean forward.

23. Ask the patient to push through their hands to stand up, looking up (rather than down at the floor) and using a forward and upward motion. Use the command “ready, steady, stand” to instruct them to stand.

24. Ask the patient to stand still for a moment to assess whether they feel light-headed and enable them to achieve balance. If they feel dizzy, ask them to sit down again on the bed and reassess.

Transfer from standing into a chair

This assumes patients can step around to the chair independently or using an aid, with only verbal guidance from the carer.

Once the patient is stable and standing with any aids in place:

25. Encourage them to step around to the chair until they feel the edge of the seat against the back of their legs.

26. Stand at the patient’s weaker side, if they have one, and place your hand that is nearest to them on the front of their shoulder.

27. Place your other hand on the patient’s lower back to guide them down as they sit.

28. Instruct the patient to bend at their hips and knees, leaning forward and pushing their bottom backwards, while reaching for the arms or seat of the chair for support.

29. Ask the patient to lower themself down into the chair, sitting back as far as possible.

Once the patient is seated, make sure they are warm and comfortable, and have at hand a call bell, drink and anything else they need. Decontaminate your hands and dispose of personal protective equipment according to local policy.

Post-transfer assessment

At the end of the procedure, document it on the patient’s mobility plan. Assess how well the transfer technique worked and whether it could have been improved in any way, making sure you ask the patient for their feedback. If there were problems, the patient may need to be reassessed and their care replanned.

Also in this series

• Early mobilisation 1: risk factors, complications and costs of immobility
• Early mobilisation 2: comprehensive mobility assessment and goal setting
• Early mobilisation 4: transferring patients safely using equipment
• Early mobilisation 5: finding solutions to support patient mobility

References

Lister S et al (2020) The Royal Marsden Manual of Clinical Nursing Procedures. Wiley-Blackwell.

Rindsland S (2021) Early mobilisation2: comprehensive mobility assessment and goal setting. Nursing Times; 117: 5, 28-30.

Royal College of Nursing (2020) Tools of the Trade: Guidance for Health Care Staff on Glove Use and the Prevention of Contact Dermatitis. RCN.

Smith J (2013) The Guide to the Handling of People: A Systems Approach. Backcare Trading.

Stephenson J (2018) Campaign to ‘End PJ Paralysis’ Saved 710,000 Hospital Days. nursingtimes.net, 21 August.

Vatwani A (2017) Caregiver guide and instructions for safe bed mobility. Archives of Physical Medicine and Rehabilitation; 98: 9, 1907-1910.

Walker J et al (2018) Reducing the effects of immobility during hospital admissions. Nursing Times [online]; 114: 6, 18-20.

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