Skill 9-3

Transferring a Patient From the Bed to a Chair

Moving a patient from the bed to a chair helps them begin engaging in physical activity. Changing a patient's position will also help prevent complications related to immobility. Safety and comfort are key concerns when assisting the patient out of bed. Before performing the transfer, identify any restrictions related to the patient's condition and determine how activity levels may be affected. Knowledge of correct body alignment, SPHM, and assistive devices to transfer the patient are crucial to achieve patient movement and avoid injury. Use a decision-making tool to help make decisions about SPHM. One suggested decision-making strategy is outlined in Fundamentals Review 9-4 and includes suggestions for associated SPHM equipment. Another example of a decision-making tool is provided in Figure 1. If the patient is fully able to assist in getting out of bed, allow the patient to complete the movement independently, with safe supervision. If the patient is partially able to assist and has upper extremity strength, sitting balance, and the ability to grasp with at least one hand, use a seated transfer aid, nonpowered standing aid, or powered standing assist device (Figure 2). If the patient is unable to assist, friction-reducing devices, lifting/repositioning sheets, lateral transfer devices, and a full-body sling are potential equipment to consider, based on screening and assessment. Fundamentals Review 9-3 reviews examples of equipment and assistive devices that are available to aid in patient movement and handling. Refer to Box 9-1 in Skill 9-1 for additional considerations related to mobility and safe handling of people with dementia. The procedure below describes general guidelines for transferring a patient out of bed to a chair. Refer to facility policy and procedures and specific manufacturer guidelines related to other available devices and equipment. Skill 9-4 describes the use of a powered full-body sling lift.

Delegation Considerations

The transfer of a patient from bed to a chair may be delegated to assistive personnel (AP) as well as to licensed practical/vocational nurses (LPN/LVNs). The decision to delegate must be based on careful analysis of the patient's needs and circumstances as well as the qualifications of the person to whom the task is being delegated. Refer to the Delegation Guidelines in Appendix A.

Equipment

Chair or wheelchair
Gait belt
Stand-assist aid, seated transfer aid, nonpowered standing aid, powered standing assist device, or ceiling lift or full-body lift, based on assessment
Additional staff person(s) to assist
Blanket to cover the patient in the chair
Nonsterile gloves and/or other PPE, as indicated

Assessment

Assess the situation to determine the need to get the patient out of bed. Review the health record for conditions that may influence the patient's ability to move or to be transferred. Perform a pain assessment before the time for the activity. If the patient reports pain, administer the prescribed medication in sufficient time to allow for the full effect of the analgesic. Check for tubes, IV lines, incisions, or equipment that may require modifying the transfer procedure. Assess the patient's level of consciousness, ability to understand and follow directions, and ability to assist with the transfer. Use available algorithms or other decision-making tools to aid in assessment and decision making. Determine the need for bariatric equipment.

Actual or Potential Health Problems and Needs

Many actual or potential health problems or issues may require the use of this skill as part of related interventions. An appropriate health problem or issue may include:

Activity intolerance
Fall risk
Deconditioning

Outcome Identification and Planning

The expected outcome to achieve when transferring a patient from the bed to a chair is that the transfer is accomplished without injury to the patient or nurse.

Implementation

Action	Rationale
1. Review the health record for prescribed interventions and plan of care for patient activity. Identify any movement limitations, conditions that may influence the patient's ability to move or be positioned, and the ability of the patient to assist with the transfer. Assess for tubes, IV lines, incisions, or equipment that may alter the positioning procedure. Consult a patient handling algorithm or other decision-making tool to plan an appropriate approach to moving the patient. Gather transport aids or supports as necessary.	Reviewing the health record and care plan validates the correct patient and correct procedure. Identification of limitations and ability and use of an algorithm help to prevent injury and aid in determining best plan for patient movement. Having aids readily available promotes efficient time management.
2. Perform hand hygiene and put on PPE, as indicated.	Hand hygiene and PPE prevent spread of microorganisms. PPE is required based on transmission precautions.
3. Identify the patient. Explain the procedure to the patient.	Patient identification validates the correct patient and correct procedure. Discussion and explanation help allay anxiety and prepare the patient for what to expect.
4. If needed, move equipment to make room for the chair. Close the curtains around the bed and close the door to the room, if possible.	A clear pathway from the bed to the chair facilitates the transfer. Closing the door or curtains provides for privacy.
5. Place the bed in a position that allows the patient's feet to reach the floor. Raise the head of the bed to a sitting position, or as high as the patient can tolerate.	Proper bed height and positioning facilitate the transfer. The amount of energy needed to move from a sitting position or elevated position to a sitting position is decreased.
6. Make sure the bed brakes are locked. Put the chair next to the bed. If available, lock the brakes of the chair. If the chair does not have brakes, brace the chair against a secure object.	Locking brakes or bracing the chair prevents movement during transfer and increases stability and patient safety.
7. Encourage the patient to make use of a stand-assist aid, either freestanding or attached to the side of the bed, if available, to move to the side of the bed and to a side-lying position, facing the side of the bed on which the patient will sit.	Encourages independence, reduces strain for staff, and decreases risk for patient injury.
8. Lower the side rail, if necessary, and stand near the patient's hips. Stand with your legs shoulder width apart with one foot near the head of the bed, slightly in front of the other foot.	The nurse's center of gravity is placed near the patient's greatest weight to assist the patient to a sitting position safely.
9. Encourage the patient to make use of the stand-assist device (Figure 3). Assist the patient to sit up on the side of the bed; ask the patient to swing their legs over the side of the bed. At the same time, the patient should use the stand-assist device to sit upright at the side of the bed.	Gravity lowers the patient's legs over the bed.
10. Stand in front of the patient, and assess for any balance problems or complaints of dizziness. Allow the patient's legs to dangle a few minutes before continuing.	Standing in front of the patient prevents falls or injuries from orthostatic hypotension. The sitting position facilitates transfer to the chair and allows the circulatory system to adjust to a change in position.
11. Assist the patient to put on a robe, as necessary and skid-proof footwear.	Robe provides warmth and privacy. Nonskid soles reduce the risk for falling.
12. Wrap the gait belt around the patient's waist, based on assessed need and facility policy (Figure 4).	Gait belts improve the caregiver's grasp, reducing the risk of musculoskeletal injuries to staff and the patient. The belt also provides a firmer grasp for the caregiver if the patient should lose their balance. A gait belt is used to steady the patient, not a lifting device (Wintersgill, 2019).
13. Encourage the patient to make use of the stand-assist device. Cue the patient to stand. Assess the patient's balance and leg strength. If the patient is weak or unsteady, return the patient to the bed.	Use of a stand-assist device decreases the risk of injury to the nurse and to the patient. Assessing balance and strength helps to identify the need for additional assistance to prevent falling.
14. Assist the patient to pivot and turn until the patient feels the chair against their legs.	This action ensures proper positioning before sitting.
15. Ask the patient to use their arm to steady themselves on the arm of the chair while slowly lowering to a sitting position.	The patient uses their own arm for support and stability.
16. Assess the patient's alignment in the chair. Remove the gait belt, if desired. Depending on patient comfort, it could be left in place to use when returning to bed. Cover with a blanket, if needed. Make sure call bell and other essential items are within easy reach.	Assessment promotes comfort; blanket provides warmth and privacy; having the call bell and other essential items readily available helps promote safety.
17. Clean transfer aids, per facility policy, if not indicated for single-patient use. Remove gloves and any other PPE, if used. Perform hand hygiene.	Proper cleaning of equipment between patient use prevents the spread of microorganisms. Proper removal of PPE reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents the spread of microorganisms.

Evaluation

The expected outcome has been met when the patient has transferred from the bed to the chair without injury to the patient or nurse.

Documentation

Guidelines

Document the activity, including the length of time the patient sat in the chair, any other pertinent observations, and the patient's tolerance of and reaction to the activity. Document the completed assessment algorithm for patient handling and movement decision and the use of transfer aids and number of staff required for transfer.

Sample Documentation

Developing Clinical Reasoning and Clinical Judgment

Unexpected Situations and Associated Interventions

You are assisting a patient out of bed. The previous times the patient has gotten up, you have not had any difficulty helping him by yourself, so you are working alone at this time. The patient is positioned on the side of the bed and uses the stand-assist device to stand. As you move to pivot to the chair, the patient becomes very lightheaded and weak and his knees buckle: Do not continue the move to the chair. Lower the patient back to the side of the bed. Pivot him back into bed, cover him, and raise the side rails. Check vital signs and assess for any other symptoms. After his symptoms have subsided and you are ready to get him up again, arrange for the assistance of another staff member. Have the patient dangle his legs for a longer period of time before standing. Assess for lightheadedness or dizziness before helping him to stand. Notify the health care team if there are any significant findings or if his symptoms persist.

Special Considerations

Transfer of a patient to a chair or toilet can be accomplished using a powered stand-assist and repositioning lift, if available. These devices can be used with patients who have weight-bearing ability on at least one leg and who can follow directions and are cooperative. A simple sling is placed around the patient's back and under the arms. The patient rests feet on the device's footrest and places their hands on the handle. The device mechanically assists the patient to stand, without any lifting by the nurse (see Fundamentals Review 9-3). Once the patient is standing, the device can be wheeled to a chair, the toilet, or bed. Some devices have removable footrests and can be used as a walker. Some have scales incorporated into the device that can be used to weigh the patient.
Patients who are unable to bear partial weight or full weight or who are uncooperative, as well as bariatric patients, should be transferred using a full-body sling lift (VHACEOSH, 2016) (refer to Skill 9-4). Use of SPHM equipment is necessary to reduce risk of injury to patient and care providers (Fragala et al., 2016; OSHA and Joint Commission Resources Alliance, 2017; VA Mobile Health, n.d.).
Consider use of a gait belt for any patient who is not independent to promote safety (Wintersgill, 2019). A gait belt is used to steady the patient, not a lifting device (Wintersgill, 2019).
Gait belts should also not be used with patients exhibiting behavioral aggression, as the belt might be used as a weapon and for patients at risk for suicide, as the belt might be used for self-harm (Wintersgill, 2019).
Keep in mind that the transfer of patients is often delegated to assistive personnel. Before moving patients, all personnel need to complete instructions about this skill and must be able to provide return demonstrations of transfer skills. When a patient is being transferred, communicate clearly any mobility restrictions or special care needs.
Bariatric patients require additional caregivers and expanded capacity devices (VA Mobile Health, n.d; VHACEOSH, 2016). Institute Bariatric Algorithms for any patient who weighs more than 300 lb, or is 100 lb over ideal weight, or who has a BMI over 40 (VHA CEOSH, 2015).

EVIDENCE FOR PRACTICE

Safe Patient Handling and Mobility

VA Mobile Health. (n.d.). Safe patient handling. (Version 1.3.3). [Mobile app]. U. S. Department of Veteran Affairs. https://mobile.va.gov/app/safe-patient-handling

VHA Center for Engineering & Occupational Safety and Health (CEOSH). (2015). Bariatric safe patient handling and mobility guidebook: A resource guide for care of persons of size. https://www.asphp.org/wp-content/uploads/2011/05/Baraiatrice-SPHM-guidebook-care-of-Person-of-Size.pdf

Refer to details in Skill 9-1, Evidence for Practice.

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Skill 9-3

EVIDENCE FOR PRACTICE