Safe Patient Handling Research Articles

Investigating emergency nurses’ beliefs and experiences with patient handling in the emergency department

BackgroundPatient handling policy intends to decrease the risk of musculoskeletal injury for nurses. Many factors influence nurses’ adherence to patient handling policy, including the context in which the activities take place. The aim of this study was to investigate emergency nurses’ beliefs and experiences with patient handling in the emergency department. MethodsA phenomenological approach was used to explore the participants’ experience of patient handling in the ED. Focus group interviews were held in a Victorian emergency department. The interviews were audio-recorded, transcribed, and the data were analysed using thematic analysis. ResultsFive interviews were held with 40 nurse participants. Four themes were identified that described participants beliefs and experiences of patient handling: ‘Putting the patient first’ describes participants prioritisation of patient safety over their own; ‘Patient -related challenges’ describes the patient factors (e.g. language, mobility, size) that make patient handling more difficult; ‘Staff knowledge’ of policy and procedure; and ‘Inadequate resources’ which describes the physical and human resource limitations that made patient handling more difficult. ConclusionsIssues with equipment, education and patient handling culture are widespread, and this study reaffirms the importance of considering context in developing interventions to improve practice. Introduction of a Safe Patient Handling Program in the ED, that addresses multiple barriers simultaneously, may improve adherence to policy, and reduce the risk of musculoskeletal injury in emergency nurses.

Use of Champions Identified by Social Network Analysis to Reduce Health Care Worker Patient-Assist Injuries

Safe patient handling and mobility (SPHM) programs recommend having champions, but have not indicated how to identify them and have confined their role to peer-based activities, limiting their ability to influence control measures. In a pilot program conducted at a community access hospital in Oregon, researchers applied social network analysis (SNA) of safety advice to identify champion candidates. Candidates were invited to complete mobility, communication, and quality improvement (QI) training modules to become champions. Champions' roles included peer-based instruction and participation in QI quarterly meetings with hospital leaders. The program process was evaluated through weekly e-mail check-ins and documentation of quarterly meetings. Outcomes were evaluated with a pre-post design, observing 12-month changes in self-reported leading indicators and Good Catch reports, as well as trends in patient-assist injuries (2011-2019). SNA identified six candidates, four of whom became champions. Champions completed 48 weekly logs. The quarterly meetings concerned unitwide SPHM training, equipment storage, and onboarding. Results showed significant improvements in equipment use, safety participation, and safety compliance, particularly among workers who would seek SPHM advice from champions or recently hired workers. Compared with the prior year, the Good Catch monthly entries increased from 11.69 to 28.81. The average annual incidence rate of patient-assist injuries dropped from 13.01 for the six years before the program to 3.7 per 100 full-time equivalents (FTE) for the two years after. A program with SNA-identified and QI-trained champions improved safety outcomes after one year. Better-designed evaluations are needed to establish the replicability and long-term impact of this program.

Safe Patient Handling and Movement.

Safe Patient Handling and Movement.

Simulation to Teach Safe Patient Handling and Mobility for Home Caregivers

Safe patient handling and mobility (SPHM) programs are needed in the home care environment. As patient-lifting technology and devices become more widely available for use in the home setting, caregivers need opportunities to learn how to properly use these devices. Nonmedical caregivers employed by personal support services agencies (PSSAs) and home caregivers have very limited access to opportunities for SPHM training in rural areas of Tennessee. Safe patient handling and mobility training utilizing simulation with an interprofessional approach was developed and provided to 17 nonmedical and family home caregivers. The training was evaluated utilizing Kirkpatrick’s Four-Level Training Evaluation Model. Participants completed anonymous surveys immediately following the training and 4 to 6 weeks after the training. Survey I (n = 17): Respondents indicated increased knowledge of safe patient handling (94%) and applied knowledge of safe patient handling in training (90%). Survey II (n = 6): Most respondents (67%) indicated that they had applied the knowledge and skills that they had learned in the training. Two respondents (33%) indicated that they had not yet had the opportunity to apply the knowledge and skills they learned. The survey also showed that all respondents believed that the knowledge and skills they had learned helped to decrease the risk of personal injury and injury to patients. Safe patient handling and mobility training utilizing simulation with an interprofessional approach was effective in promoting safety of nonmedical and family caregivers in the home setting. Based on the success of this program, more training opportunities should be implemented to improve patient and caregiver safety.

Simulation-based training programme and preparedness testing for COVID-19 using system integration methodology

BackgroundCOVID-19 pandemic is presenting serious challenges to the world’s healthcare systems. The high communicability of the COVID-19 necessitates robust medical preparedness and vigilance.ObjectiveTo report on the simulation-based training and test...

The use of safe patient handling and mobility equipment in rehabilitation.

Increasingly, occupational and physical therapists are using safe patient handling and mobility (SPHM) equipment, such as mechanical lifts, in rehabilitation. However, there is little guidance in the literature on how SPHM equipment can be used to assist patients to reach rehabilitation goals. The purpose of this projectwas to document and categorize common and innovative ways rehabilitation therapists use SPHM equipment in their clinical practice. This article investigates common and innovative uses of SPHM equipment in rehabilitation practice. Occupational, physical and kinesio therapist employed at the Veterans Health Administration wrote narratives and took photos describing rehabilitation therapy activities where they used SPHM equipment in their clinical practice. The authors used a systematic process to review and categorize the narratives and subsequent photos by using the World Health Organization's International Classification of Functioning, Disability and Health (ICF). Thirty narratives (13 innovative and 17 common) were coded into four categories on the ICF section of mobility. The most common category was "changing and maintaining basic body position"(21) followed by "walking and moving" (5). The category "carrying, moving and handling objects" garnered two narratives and there were no narratives for "using transportation." Project findings may serve as a guide for therapists who would like to enhance their use of SPHM equipment in rehabilitation. Additional research is needed to expand the use of SPHM in rehabilitation practice and evaluate the impact on patient rehabilitation outcomes and therapist safety outcomes.

Preventing Staff Member Injury Through Safe Patient Handling and Movement.

AORN JournalVolume 111, Issue 5 p. 567-568 Column Preventing Staff Member Injury Through Safe Patient Handling and Movement Lisa Spruce DNP, RN, CNS-CP, CNOR, ACNS, ACNP, FAAN, Lisa Spruce DNP, RN, CNS-CP, CNOR, ACNS, ACNP, FAANSearch for more papers by this author Lisa Spruce DNP, RN, CNS-CP, CNOR, ACNS, ACNP, FAAN, Lisa Spruce DNP, RN, CNS-CP, CNOR, ACNS, ACNP, FAANSearch for more papers by this author First published: 28 April 2020 https://doi.org/10.1002/aorn.13023Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Volume111, Issue5Special Focus Issue: Infection PreventionMay 2020Pages 567-568 RelatedInformation

Integrating Safe Patient Handling and Early Mobility: Combining Quality Initiatives.

Safe Patient Handling and Mobility (SPHM) programs reduce staff injuries from lifting and repositioning patients. Early Mobility programs improve many patient-centered outcomes. Reframing SPHM equipment as mobilization tools can help safely mobilize hospitalized patients to their highest abilities. Combining SPHM and Early Mobility programs is logical, but to date, no one has articulated the process of integration. A quality improvement process was developed at the Phoenix Veterans Affairs Health Care System to integrate an Early Exercise and Progressive Mobility initiative in the intensive care unit into an ongoing SPHM program using the Iowa Model for Evidence-Based Implementation. Integration of these programs was possible through extensive collaboration between stakeholders throughout planning, implementation, and refinement phases. Interdisciplinary Early Exercise and Progressive Mobility simulation training, standardized assessment, communication of patient status, and appropriate equipment use facilitated staff confidence to safely mobilize patients. Successful integration of Early Exercise and Progressive Mobility and SPHM was achieved at the Phoenix Veterans Affairs Health Care System.

Increasing Patient and Student Nurse Safety Using Safe Patient Handling

BackgroundAlthough hospitals in New York State have instituted safe patient handling programs as a response to a legislative mandate, evidence indicates nursing schools have lagged behind with these changes and are teaching outdated information. The purpose of this change project was to assess the effectiveness of an educational intervention (didactic and hands-on) to improve nursing student knowledge and safe use of patient handling equipment currently found in the clinical setting. MethodNursing students were provided small group educational sessions over a six-week period at an associate degree nursing school in New York. Open laboratory practice sessions for safe patient handling were provided. ResultsThe nursing students (N = 34) completed pre- and post-tests to determine improvement in knowledge and were required to complete a competency on equipment use. ConclusionThe educational intervention resulted in improved nursing student knowledge and the demonstration of safe use of patient handling equipment.

Hospitalized Adults With Intellectual and Developmental Disabilities: Confronting Challenges

Background: The hospitalization of adults with intellectual and developmental disabilities (IDD) presents unique challenges for individuals, their families, and care providers. These challenges include longer lengths of stay, higher rates of readmission, increased risk for complications related to multiple comorbidities, and poorer hospital experiences. Physical therapists and physical therapist assistants as members of interdisciplinary teams are well positioned to enhance the hospital experience and outcome optimization of persons with IDD when they are acutely ill and more vulnerable. Purpose and Methods: Following a brief review highlighting the effect of aging for adults with IDD along with common reasons for hospitalization and potential negative sequelae, the primary purpose of this article is to identify and confront challenges to enhance the hospital experience and outcomes of hospitalized adults with IDD. Practical advice is provided regarding examination and evaluation guidelines, early mobilization and safe patient handling, and strategies fostering continuity of care. Conclusion: Embracing these challenges ultimately facilitates return to prior or enhanced levels of activity and participation for adults with IDD.

Abstract WP461: Stop in the Name of Falls

Background and Purpose: One of OhioHealth’s strategic priorities includes improving patient safety by eliminating preventable patient harm. The Integrated Stroke Unit (ISU) at Riverside Methodist Hospital worked to achieve this goal by reducing falls by 20%. The ISU consistently experienced a higher fall rate compared to like units across the nation. The ISU averaged over 7 falls per month with injury falls steadily increasing. The ISU experienced inconsistencies related to fall risk assessment and fall prevention interventions. As a result, a Fall Risk Scorecard was created to streamline interdisciplinary team work, increase patient safety, and improve safe patient handling and mobility. Methods: A multidisciplinary approach was used to improve patient safety and determine the root cause for patient falls. A team of nurses, rehab therapist, and patient support assistants was established. Inconsistencies were identified related to recognition of patients at risk for falls, types of fall interventions in place, and bed alarm knowledge and utilization. A need for visual management to standardize practice was seen. A Fall Risk Scorecard was created to help identify fall risk patients, standardize fall prevention interventions, and provide knowledge to staff regarding the patient’s activity level. The PDSA cycle was used to create standard work for the care team. Educational materials were developed and one-on-one training was provided to staff. The multidisciplinary approach helped to create a standardized process for each therapist coming to the ISU. The Fall Risk Scorecard was piloted for 3 months. Results: During the pilot, the unit saw a 57% reduction in falls. Current state, the ISU has continued to utilize the Fall Risk Scorecards and has sustained a 57% reduction in falls. With the utilization of lean methodology, members of the care team were able to ensure the right patient received the right intervention at the right time. With these results, the pilot has been selected for a system-wide roll-out over 11 different care sites. Conclusion: By taking a collaborative approach, utilizing lean methodology, and real-time problem solving, the ISU has successfully reached their goal to increase patient safety and improve safe patient handling and mobility.

Rural populations exposed to Ebola Virus Disease respond positively to localised case handling: Evidence from Sierra Leone

At the height of the Ebola epidemic in Sierra Leone in November 2014, a new decentralized approach to ending infection chains was adopted. This approach was based on building local, small-scale Community Care Centres (CCC) intended to serve as triage units for safe handling of patients waiting for test results, with subsequent transfer to Ebola Treatment Centers (ETC) for those who tested positive for Ebola. This paper deals with local response to the CCC, and explains, through qualitative analysis of focus group data sets, why this development was seen in a positive light. The responses of 562 focus group participants in seven villages with CCC and seven neighbouring referral villages without CCC are assessed. These data confirm that CCC are compatible with community values concerning access to, and family care for, the sick. Mixed reactions are reported in the case of "safe burial", a process that directly challenged ritual activity seen as vital to maintaining good relations between socially-enclaved rural families. Land acquisitions to build CCC prompted divided responses. This reflects problems about land ownership unresolved since colonial times between communities and government. The study provides insights into how gaps in understanding between international Ebola responders and local communities can be bridged.

Predictors of musculoskeletal symptoms in radiology technologists in Austria, Europe.

Musculoskeletal symptoms (MSS) are a major health problem in health professionals. However, there is very little evidence about predictors of MSS in the group of radiology technologists. The aim of this study was to identify prevalence and predictors of MSS in radiology technologists working in Austrian Hospitals. 272 radiology technologists completed a self-report questionnaire including MSS, work demands, work strain and well-being (WHO-5 questionnaire). Lower back pain and upper back pain are the most frequent MSS in radiology technologists. A high proportion of participants experience these symptoms every day (20.1% and 19.8%, respectively). Work strain, age and well-being were the best predictors for MSS in a regression model. MSS is a major health issue for radiology technologist working in hospitals. Our results provide evidence for the assumption that psychological factors play an important role in development of MSS. Thus, beside physical health promotion programs (e.g. safe patient handling), psychological intervention may have positive effects on MSS.

Factors associated with safe patient handling practice in acute care and its relationship with patient mobilization: A cross-sectional study

BackgroundMobilizing hospital patients is associated with improved outcomes and shorter length of stay. Safe patient handling and mobility programs that include mechanical lift use facilitate mobilizing patients and reduce the likelihood of musculoskeletal disorders in staff. However, there is little information on the prevalence of lift use or why some patients are more likely to have a lift used than others. Such information is needed to inform public policy, benchmark lift use over time, and contextualize barriers for lift use. ObjectiveTo determine the percentage of patients that had a lift used during care in US acute care facilities, identify attributes related to the patient and their hospital stay that affect the lift use, examine whether state legislation increased lift use, and determine whether lift use was correlated with more frequent mobilization out of bed. DesignRetrospective analysis of the 2018 International Pressure Ulcer Prevalence ™ data. Participants40,856 patients in 642 US acute care hospitals over the age of 18 with complete data. MethodsLift use prevalence was calculated as the percentage of patients that met inclusion criteria that had a lift used for care. Prevalence was then analyzed by patient mobility level. A logistic regression examined the influence of patient and facility related attributes. For patients with limited mobility (that could not stand or turn themselves), a t-test of proportions evaluated whether lift use during a patient's stay was correlated with an increased likelihood of being out of bed at the time of the survey. Results3.7% of patients had a lift used during their care. 11.1% of limited mobility patients had a lift used. Lift use was associated with higher body mass, longer length of stay, lower Braden score, pressure injury prevention methods in place, being in an intensive care unit, being in a smaller hospital, and being in a state with safe patient handling and mobility legislation. Limited mobility patients moved with lifts during their stay were more likely to be observed in a bedside chair and less likely to be observed in bed, as compared to patients that never had a lift used. ConclusionsDespite the benefits to patients and caregivers, US acute care facilities are largely not using lifts to safely mobilize patients. Results suggested that safe patient handling and mobility legislation has increased the rate of lift use. Finally, lift use was correlated with patients being mobilized out of bed.

An innovative experiential interprofessional education activity using physical therapy students to teach medical students how to safely handle patients

Abstract Safe patient handling is important for preventing neuromusculoskeletal strain and injuries in healthcare workers and in patients. Physical Therapists often use their knowledge of proper body mechanics, ergonomic safety, injury and fall prevention to train members of the multidisciplinary health care team in safe patient handling and movement. In order to be effective educators and design appropriate training programs, physical therapists need to be knowledgeable about other healthcare team members’ job duties and work environments. When medical students begin clinical rotations they are confronted with the task of assisting patients to move from the interview chair to the exam table or helping a bedridden patient sit up on the side of the bed and then stand, but these skills are rarely if ever included in the medical curriculum. In order to introduce medical students to safe patient handling and movement techniques we designed a novel experiential interprofessional education (IPE) session in which physical therapy students developed teaching materials and taught medical students how to safely manage patient mobility from bed to standing to chair and from exam table to and from chair. After a single 90-min session, the medical students demonstrated improved knowledge and confidence in safe patient handling and movement skills. In addition, both groups of students interacted professionally and learned about each other's disciplines.

MOBILITY EDUCATION FOR THE DIVERSE AGING COMMUNITY, CAREGIVERS, AND THEIR HEALTH CARE PROVIDERS

Older adults can reduce fall risk in their homes and the community. Health care professionals (HCP) have a role in preventing falls. An interprofessional team of HCPs at a comprehensive cancer center created and delivered educational workshops to increase knowledge about falls prevention. Educational workshops were provided in community centers, libraries, places of worship and at local hospitals to medically underserved, diverse community members, caregivers and HCP. An Occupational (OT) and Physical Therapist (PT) taught three workshops together and the OT taught nine workshops. Workshops included fall prevention, home modifications, safe patient handling (SPH), and the role of OT/ PT in geriatric oncology care. Practical and culturally competent steps were emphasized, with translation of written materials and live interpretation provided as appropriate. Knowledge increase was assessed, and post-session qualitative data was collected. The mean age of community members was 68 years, of nurses was 42, and of caregivers 63. A majority of participants were female. 220 older adults completed surveys, 40 caregivers, and 11 registered nurses. The Falls Prevention workshops with unmatched (n=79) and matched data (n=140) showed significant improvements in knowledge [t(135)=-3.33, p<0.001; t(139)=-4.03, p<.001; respectively). Caregivers who participated in the SPH workshop improved their learning for the unmatched (n=12) and matched data (n=28) after participating in the workshops [t(22)=-3.50, p=.002; t(27)=-3.95, p<.001] respectively. For nurses, the change in scores from pre (M=.56) to post scores (M=.73) were significant (t=-2.76, df=10, p=.02). Caregivers and HCPs benefit from continued education to promote safer, holistic care for family members and patients.

Integration of Safe Patient Handling and Mobility Principles in Professional Physical Therapist Education: A Case Report

Background and Purpose. Safe patient handling and mobility (SPHM) programs are being used across the country to safely transport and mobilize patients while at the same time reducing injury risk to caregivers, including physical therapists (PT) and physical therapist assistants (PTA). The American Physical Therapy Association has called PTs and PTAs to not only use the concepts of SPHM in clinical practice, but also be leaders in utilization, development, and implementation of SPHM programs, including training and education of other health care team members. Perlow, et al have recommended that SPHM content be integrated into Doctor of Physical Therapy (DPT) education. This case report outlines 1 current module used to deliver such content. Case Description. A neurologic interventions course within the DPT curriculum was selected using a framework that linked content, objectives, and learning activities with relevant Normative Model criteria and Physical Therapist Code of Ethics to improve student self-efficacy with SPHM content. Primary goals were to improve student awareness about risk and impact of work-related musculoskeletal disorders, expose students to the expected role of the PT as an advocate for and educator in SPHM programs, and provide hands-on experience with SPHM technologies. The 6-hour session was completed in 1 day with a 1-hour lecture and 5 hours with a variety of hands-on activities. Outcomes. Student learning was assessed through a pre–post class questionnaire, documentation/discussion of experiences, and presentations of student-generated neurologic interventions using SPHM equipment. Awareness of increased risk of injury, limits of 'good' body mechanics, and feasibility of using SPHM technologies to improve the quality of physical therapy practice dramatically increased. Discussion. Students should participate in a variety of learning activities threaded through the curriculum to provide sufficient hands-on opportunities to improve self-efficacy in using SPHM principles in rehabilitation. By developing a basic level of competency with SPHM principles, students may be more likely to adopt SPHM as a professional value once graduated. Improvements to this model, recommendations for SPHM integration into DPT curricula, and research opportunities are discussed. Conclusion. We have provided 1 model that embeds SPHM content into entry-level physical therapist education. In doing so, educators are advancing physical therapy skills needed to apply evidenced-based therapeutic principles in difficult to move patients while reducing risk of injury to students and new graduates of the profession.

An Innovative, Multimodal Approach to Help Obstetric Nurses Realize That Caring for Bariatric Patients Is a Challenge

Obesity rates have increased dramatically worldwide over the past 20 years, and it is known that obesity negatively impacts obstetric and neonatal outcomes. Accurate determination and documentation of body mass index (BMI) at hospital admission are crucial for guiding appropriate patient care and nursing preparation. Work-related injuries are major safety concerns in the nursing profession, and risk for injury increases when caring for patients who are obese. Knowledge and use of safe patient handling techniques and safe patient mobilization devices have been shown to decrease risk for nurse injury and have the potential to prolong nursing career viability. Interpersonal, situational, organizational, and environmental influences impact nurses’ willingness to engage in safe patient handling and mobility. The purpose of this evidence-based practice project was to use innovative educational strategies to increase knowledge related to caring for obstetric patients who are obese. Results of a preintervention survey guided development of unit- and population-specific training to improve patient care and safety, increase use of safe patient mobilization techniques, reduce rate of nurse injury, and improve nursing documentation in the electronic medical record to accurately indicate the patient’s BMI. After a preintervention survey was administered, focused video and hands-on training was provided to nurses regarding how to safely care for obstetric patients who are obese. Content included correct BMI determination and documentation on admission, use of bed features and ergonomics to prevent nurse injury, and techniques to prevent postdelivery infection. The information also addressed the organizational and cultural influences that impact nurses’ willingness to engage in safe patient handling techniques. Significant improvements in knowledge and performance were noted at 1-, 3-, and 6-months postintervention, and nurse injury rates related to sprains and strains decreased. Pre- and postintervention evaluations included nurses’ level of knowledge, practice, and confidence related to caring for obstetric patients who are obese; rate of nurse injury on the involved nursing units; and compliance rates of documentation of BMI in the electronic medical record. Knowledge of appropriate safe patient handling and mobilization techniques is not enough to ensure consistent use during intrapartum patient care. The reduction of interpersonal and organizational barriers can improve patient care and decrease nurse injury.

Safe Patient Handling: How Many People Do You Need to Safely Lateral Transfer Patients?

Abstract Background: Although friction-reducing devices reduce the amount of force to complete a lateral transfer, the total force is significantly higher than the recommended pushing and pulling limits. Caregivers complete lateral transfers without knowing the amount of force required to laterally transfer patients, which subjects them to injury. Methods: This study was designed to identify the force to laterally transfer patients of any weight, in conditions similar to those found within the hospital of this study. There were 16 participants in this study. The participants were moved from a hospital bed to a hospital cart using two force gauges pulling two gait belts secured around the participant. Each participant was moved three times, resulting in 48 data points. A regression analysis was used to evaluate trends between two variables. A general linear model was applied and the coefficient of determination was calculated to show the percent fit to the trend line. Results: This study found a strong correlation between force of lateral transfer and the weight of the patient. Using this correlation, this study was able to predict the total force of a lateral transfer for any patient weight. The results from this study allowed for the creation of a guide to determine how many caregivers are required during a lateral transfer to maintain a safe amount of force per caregiver. Conclusion: Caregivers need to be given information regarding the forces required to complete physical movements so they can protect themselves from overexertion and injury. This study provides a guideline for caregivers to know how many people are needed to safely complete a lateral transfer.

Accessibility and accommodations for patients with mobility disabilities in a large healthcare system: How are we doing?

BackgroundPeople with disabilities continue to experience health disparities resulting from inaccessibility of healthcare practices and medical diagnostic equipment (MDE). ObjectiveThe purpose of this study was to evaluate the accessibility of and accommodations for patients with mobility disabilities in clinics of a large healthcare system in the South Atlantic division of the U.S., to determine if accessibility was different based on clinic type, and to identify areas for improvement to increase accessibility. MethodsThis was a cross-sectional study of 214 healthcare professionals conducted between March and June of 2018. Chi square tests and ANOVA were used to compare accessibility between primary care, hospital based, and private diagnostic clinics. ResultsA relatively high proportions of respondents reported that their clinic had implemented many accessible features. However, significant differences were found by clinic type with primary care clinics having better access to MDE including height adjustable exam tables, scales with handrails, wheelchair accessible scales, or padded leg supports. However, primary care clinics were less likely to have lifts for transferring patients. The percent of clinics with MDE was higher than that reported in previous studies which may be due to the safe patient handling and mobility program implemented at the healthcare system. Accommodations for patients when a barrier to care is encountered remain an area for improvement. ConclusionWhile accessibility for people with disabilities was greater in this healthcare system, areas for improvement were identified to help healthcare professional care for their patients with disabilities.