Compliance of standard operating procedures for patient handling in university hospitals: assessment of prescribed work

Abstract

Objective  To analyze the prescribed work related to patient transport and manual handling tasks.

Methods  The three stages of content analysis were carried out: 1) pre-analysis; 2) exploration of the material; 3) processing of results and interpretation. The search for Standard Operating Procedures (SOPs) was conducted on the websites of University Hospitals (UHs) and via email. A total of 33 SOPs from UHs administered by the Brazilian Hospital Services Company (EBSERH) were analyzed. The interpretation was based on the requirements of the Consolidation of Labor Laws, Regulatory Standards 17 and 32, and Resolution No. 63 of the Collegiate Board of the National Health Surveillance Agency.

Results  The analysis identified 55 associations or equivalences with regulatory requirements in 20 SOPs (60.6% of the documents). The most frequent items were related to recommendations for teamwork, workplace organization, use of technical aids, use of “proper body mechanics,” and encouragement of patient cooperation. On the other hand, of the regulatory items considered, six were not met by any of the SOPs.

Conclusion  The study identified heterogeneous content in the prescribed work and omissions in meeting certain requirements related to the transport and handling of loads.

Keywords
Occupational Health; Legislation, Labor; Legislation as Topic; Enacted Statutes; Hospitals, University; Moving and Lifting Patients

Resumo

Objetivo  Analisar o trabalho prescrito relacionado com tarefas de transporte e movimentação manual de pacientes.

Métodos  Foram realizadas as três etapas de análise de conteúdo: 1) pré-análise; 2) exploração do material; 3) tratamento dos resultados e interpretação. A busca dos Procedimentos Operacionais Padrão (POPs) foi realizada nos portais dos Hospitais Universitários (HUs) e por meio de mensagem de correio eletrônico. Foram analisados 33 POPs dos HUs administrados pela Empresa Brasileira de Serviços Hospitalares (EBSERH). A interpretação foi baseada nas exigências da Consolidação das Leis do Trabalho, Normas Regulamentadoras 17 e 32 e Resolução da Diretoria Colegiada nº 63 da Agência Nacional de Vigilância Sanitária.

Resultados  A análise desenvolveu 55 associações ou equivalências com os requisitos normativos em 20 POPs (60,6% dos documentos). Os itens mais frequentes foram relacionados com a recomendação para o trabalho em equipe, organização do ambiente, uso de meios técnicos facilitadores, uso de uma “mecânica corporal correta” e estímulo para a cooperação do paciente. Por outro lado, dos itens normativos considerados, seis não foram atendidos por nenhum dos POPs.

Conclusão  O estudo identificou um conteúdo heterogêneo do trabalho prescrito e omissão no atendimento a alguns requisitos relacionados com o transporte e movimentação de cargas.

Palavras-chave
Saúde do Trabalhador; Legislação Trabalhista em Saúde; Legislação como Assunto; Normas Legais; Hospitais Universitários; Movimentação e Transferência de Pacientes

Introduction

Brazilian legislation includes laws, resolutions, and standards aimed at strengthening workers’ health¹. Harmonization among regulatory standards is essential for the effectiveness of ergonomic management and for legal certainty in labor relations. Therefore, regulatory instruments must be complementary and systemic in nature².

The Consolidation of Labor Laws (CLT), enacted by Decree-Law No. 5,452 on May 1, 1943¹, established preventive measures against occupational diseases and workplace accident risks. The Regulatory Standards (NRs) serve as complementary provisions to the CLT. Specifically, in the field of ergonomics and worker health, NR-17 establishes the guidelines and requirements that enable the adaptation of working conditions to the psychophysiological characteristics of workers, ensuring comfort, safety, health, and efficient performance³. Meanwhile, NR-32, established in 2005 by the Ministry of Labor and Employment, defines fundamental guidelines to protect the safety and health of workers in healthcare services, as well as in health promotion and care activities in general⁴. Also regarding healthcare workers, the Brazilian Health Regulatory Agency (ANVISA), through Collegiate Board Resolution (RDC) No. 63 of November 25, 2011, regulates the requirements for good practices in the operation of healthcare services, with the aim of reducing the risks inherent in the provision of such services⁵. These regulations stand out as important milestones in the protection of workers’ health and safety in Brazil, complementing the conditions set forth in the legislation¹.

In the healthcare sector, particularly in hospital settings, work is often performed under unfavorable conditions influenced by environmental and ergonomic factors⁶. This situation is particularly relevant, as circumstances related to working conditions and an excess of vigorous and repetitive movements have been responsible for workplace accidents among nursing professionals⁷. It is no coincidence that there are regulatory and legal protections for women. Article 390 of the CLT establishes that “the workload must be reduced in the case of female workers [...]”. Furthermore, the law stipulates that “the employer is prohibited from employing women in work that requires the use of muscular force exceeding 20 (twenty) kilograms for continuous work, or 25 (twenty-five) kilograms for occasional work”¹. NR-17 also establishes that the load carried must be reduced in the case of female workers³.

The type of physical exertion is directly related to the physiological workload associated with hospital duties⁸. This workload is characterized primarily by prolonged standing and the handling of heavy loads⁹.

Consequently, various activities performed in a hospital setting can place physiological strain on workers. However, the main factors contributing to this strain are largely associated with tasks involving the manual handling of patients¹⁰, which often require considerable physical effort¹¹.

An analysis of current legislation and regulations reveals that the task of manually moving patients is addressed in item 32.10.12, subitem ‘a’, of NR-32⁴: “Healthcare workers must be: a) trained to use proper body mechanics when moving patients or materials, to preserve their health and physical integrity.” However, the term “proper body mechanics” lacks a clear technical description to guide its application, nor does it provide objective criteria to define this practice, creating uncertainty regarding the parameters to be followed by healthcare facilities and professionals. Based on its ergonomic content, this recommendation could be covered by NR-17². However, the standard explicitly excludes the handling of patients, as per item 17.5.6³: “Chapter 17.5 Lifting, transport, and individual unloading of loads of this NR does not apply to the lifting, transport, and handling of people.” This exclusion creates a regulatory conflict based on the sole paragraph of Article 182 of the CLT², which establishes: “The provisions relating to the transport of materials also apply, as appropriate, to the transport of persons in the workplace”¹. Thus, it is understood that item 17.5.6 of NR-17, as a provision excluding the movement of persons, lacks legal consistency with the Brazilian legal system².

Operating procedures are essential in healthcare services, especially in the hospital sector, as they ensure that tasks are performed consistently and safely, minimizing unnecessary effort¹².The implementation of and adherence to specific protocols contribute significantly to the prevention and minimization of risks and harm in healthcare services, representing simple and effective strategies¹³. Standardization can be understood as a practice involving an assessment based on previously defined standards or guidelines¹⁴. In this context, Standard Operating Procedures (SOPs) represent the most fundamental document in this process, and their development is essential to ensure uniformity in the execution of activities¹⁵. SOPs must include, in detail, the expected outcomes of the task, a list of necessary materials, the main steps or critical activities for its execution, corrective measures in cases of non-compliance, and precautions to be communicated during the process¹⁵. In other words, the description of the prescribed work can be found in SOPs¹⁶. From this perspective, the prescribed procedure can contribute to best practices for actual work, eliminating improvisation, reducing overloads, and preventing complaints, illnesses, and occupational accidents. On the other hand, according to Dejours: “the path to be taken between the prescribed and the actual must be, at every moment, invented or discovered by the working subject”¹⁷ (p. 28). Thus, the objective of a SOP for the handling of patients with is to reduce the gap between the prescribed and the actual to prevent accidents and ensure good occupational safety and health practices.

Given the need to optimize manual patient handling tasks and the importance of Standard Operating Procedures (SOPs) in standardizing healthcare services, it is essential to systematize these procedures in university hospitals (UHs)¹⁸. This practice is significant because, as a characteristic of this educational model, UHs play a role in helping future professionals develop technical skills¹⁸. Regulatory compliance with SOPs can ensure that the prescribed work for patient handling aligns with occupational safety and health laws and standards, optimizing efforts and creating a safer and more efficient environment for patient handling in UHs. Thus, based on these considerations, this study aims to analyze the prescribed work related to tasks involving the transport and manual handling of patients in federal university hospitals administered by the Brazilian Hospital Services Company (EBSERH).

Methods

Type of study

This is a qualitative study using deductive content analysis¹⁹, in which the analytical framework was operationalized based on prior knowledge²⁰. We conducted a search and selection of SOPs from federal UHs, organized and analyzed the content, and provided a descriptive interpretation of the results obtained.

Context

EBSERH is a public entity affiliated with the Brazilian Ministry of Education. Its role is to provide health services to the community, ensuring that federal university hospitals comply with the guidelines of the Brazilian Unified Health System (Sistema Único de Saúde [SUS])²¹. According to information available on its website, linked to the Federal Government portal (gov.br)²¹, EBSERH coordinates and evaluates the implementation of activities carried out by 39 federal university hospitals belonging to 34 federal institutions of higher education.

The distribution of these hospitals across the country shows that the highest concentration is in the Northeast region, with 16 facilities (43.2%). The Southeast has nine hospitals (24.3%), while the Center-West and the South each have five (13.5%). The lowest concentration is in the North region, which has four hospitals (10.8%).

SOPs collection procedures:

To access the SOPs, we visited the institutional websites of all hospitals listed on the EBSERH website. Although some university hospitals make their SOPs available directly on their websites, in the information access section, this practice is not standardized across all hospitals. Given this situation, emails were sent to the superintendents of each institution. Thus, all listed hospitals were contacted, and requests were directed to the groups of university hospitals in each geographic region of the country. No request emails were sent to two hospitals in the Southeast region, as their institutional websites had recently been updated and made all their documents fully available.

After contacting the hospital administrators, a four-week period was allowed for each institution to respond. The search for the SOPs took place from September 15, 2024, to November 5, 2024. Once this period had elapsed, the three stages of content analysis¹⁹ began: 1) Pre-analysis; 2) Exploration of the material; and 3) Processing of results and interpretation.

1) Pre-analysis

a) Skimming

A two-stage screening process was conducted to select the SOPs: primary and secondary. The primary screening aimed to initially select the SOPs based on a review of the titles, using six predefined keywords: 1) transport; 2) movement; 3) positioning; 4) mobilization; 5) repositioning; and 6) transfer. The SOPs identified in the primary screening were grouped into a single dataset and subjected to secondary screening for document selection.

b) Selection of documents

The documents were selected using criteria designed to ensure the following principles: comprehensiveness, representativeness, homogeneity, and relevance¹⁹. The secondary screening, conducted by two researchers, involved a full reading of each SOP, with selection based on the following eligibility criteria: 1) include activities related to the transport, movement, positioning, mobilization, repositioning, and transfer of adult, pediatric, and unspecified-age patients or bodies; 2) be prepared by a university hospital affiliated with EBSERH; and 3) be freely accessible or made available in full by the administrator upon request. These criteria aimed to ensure the homogeneity of the documents to be analyzed. The appendices, instruments, and references proposed by the SOPs were reviewed to ensure the principle of exhaustiveness.

During visits to institutional websites, documents from four UHs were found; however, in two of them, the pages were not up to date. Consequently, 37 UHs were contacted. Six responded, resulting in a response rate of 16.2%. The Southeast region stood out with the highest response rate (42.8%). Of the six hospitals that responded to the contact emails, five submitted their documents as requested. Thus, a study of procedures was conducted for nine hospitals (23.0% of the listed hospitals). The Southeast region accounted for most of the identified SOPs, with 18 (54.5%). Table 1 presents the distribution of the hospitals, the response rates to the emails sent to the hospitals, and the selection of SOPs, broken down by geographic region. The number of SOPs found on the respective websites of each UH, combined with the SOPs received via email contact, represented the total number of SOPs identified during the primary screening phase. Thus, after applying the eligibility criteria during the secondary screening phase, two SOPs were excluded. Consequently, the analysis was conducted using 33 SOPs - those found or received - to ensure the representativeness of the content.

Table 1
Distribution of University Hospitals (UHs), email response rate, and identification and selection of Standard Operating Procedures (SOPs)

Region	Total number of UHs	SOPs found via website (number of UHs)	SOPs received via email (number of UHs)	Response rate - contact emails (number of UHs)	Total number of SOPs found*	Number of selected SOPs**	Number of HUs with selected SOPs
Center-West	5	-	4 (1)	20.0% (1)	4	4	1
Northeast	16	-	4 (1)	6.3% (1)	4	4	1
North	4	1 (1)	-	-	1	1	1
Southeast	9	8 (2)	12 (2)	42.8% (3)	20	18	4
South	5	3 (1)	3 (1)	20.0% (1)	6	6	2
Total	39	12 (4)	23 (5)	-	35	33	9

• * Number of SOPs found on the UH website plus those received via email.
• ** Number of SOPs selected after applying the eligibility criteria.

c) Formulation of indicators that will support the preparation for the analysis of the material:

The indicators for the use of the equipment were based on the requirements for the lifting, transport, and unloading of individual loads set forth in NR-17³(12 items), the requirements of NR-32⁴related to the movement of people (two items), and one item from ANVISA RDC No. 63⁵ related to guidelines for patient encouragement regarding the care provided, and the weight limits for workers established by Articles 198 and 390 of the CLT¹. Thus, a document analysis table with 17 items was developed (Table 2).

Table 2
List of categories and textual clues/keywords for associating or matching the content of the Standard Operating Procedures SOPs with the regulatory provisions*

	Regulatory provision	Unit of analysis	Textual clues/Keywords
17.5.1	“The manual handling of loads by a worker whose weight is likely to compromise their health, or safety shall not be required or permitted”	Restrictions on the manual handling of patients or bodies when their weight poses a risk to the health or safety of workers.	Weight Ask for help; call on the team
17.5.1.1	“The load carried must be reduced when female workers or minor workers are involved in activities permitted by law.”	Appropriateness of the load when moving patients or bodies by women or underage workers.	Women; female workers Minor worker
17.5.2	“When lifting, handling, and transporting cargo on an individual and non-occasional basis, the following requirements must be observed: (a) The areas for picking up and setting down loads, based on the preliminary ergonomic assessment or the AET, must be organized in such a way that the loads, access points, maneuvering spaces, and heights for picking up and setting down do not require the worker to perform excessive flexion, extension, or rotation of the trunk, or other forced and harmful positions or movements of body segments”	Organization of areas where patients or bodies are transferred, avoiding awkward postures or harmful movements of the trunk and body segments.	Ergonomics Height Access Bending, reaching; twisting; trunk; movements Grip Organization of the environment/spaces Seeking a neutral/upright posture
17.5.2	“b) loads and equipment must be positioned as close as possible to the worker, ensuring sufficient space for the feet, so as to facilitate reach, not hinder movements, or cause other risks.”	Position patients, stretchers, and equipment close to the worker, ensuring adequate foot space and a safe reach.	Equipment; Nearby; Space; Reach; Positioning
17.5.2.1	“The non-occasional lifting of loads that may compromise the worker’s safety and health is prohibited when the horizontal reach of the handle exceeds 60 cm (sixty centimeters) from the body.”	Prohibition on moving patients or bodies when the grip is more than 60 cm from the worker’s body.	Horizontal reach: 60 cm (sixty centimeters) Distance
17.5.3	“The transport and unloading of materials by pushing or pulling handcarts, wheelbarrows, or any other mechanical device must take into account the load, frequency, grip, and distance traveled, so as not to compromise the worker’s health or safety.”	Consideration of load, frequency, grip, and distance traveled when transporting patients or bodies, so as not to compromise the health and safety of workers.	Lifting; distance; stretcher; bed; wheelchair
17.5.4	“17.5.4 In the manual handling and non-occasional transport of loads, one or more of the following preventive measures must be adopted: a) implement technical aids”	Implementation of technical aids to facilitate the manual handling of patients or bodies.	Fitted sheet Height-adjustable stretcher Patient lift
	“b) adjust the weight and size of the load (dimensions and shape) so that they do not cause an increase in physical effort that could compromise the worker’s safety and health”	Ensuring that the load carried by each worker when moving patients or bodies is appropriate, in order to reduce physical exertion during handling.	Weight; effort
	“c) limit the duration, frequency, and number of movements performed by workers”	Limiting the duration, frequency, and number of movements performed by workers when moving patients or bodies.	Movements, duration; frequency
	“d) reduce the distances to be traveled with loads, where applicable”	Reduction of the distances traveled by workers when moving patients or bodies, where possible.	Distance, route
	“e) Alternate with other activities or take sufficient breaks at intervals of no more than two hours.”	Alternating activities or providing adequate breaks for workers during the handling of patients or bodies, in periods not exceeding two hours.	Breaks; alternation
17.5.5	“Every worker assigned to the non-occasional manual transport of loads must receive instruction on methods for lifting, loading, and unloading loads.”	Training for workers on safe methods for lifting, transporting, and positioning patients or bodies.	Guidance, training; methods for lifting, carrying, and moving
32.10.10	“In procedures for moving and transporting patients, priority should be given to the use of devices that minimize the effort required of workers.”	Availability of guidelines to minimize worker effort	Existence of guidance to minimize worker effort
32.10.12	“Healthcare workers must be: a) trained to use proper body mechanics when moving patients or materials, in order to protect their health and physical well-being”	Training of workers to use proper body mechanics when moving patients or bodies, preserving their health and physical integrity.	Training, workshops Pursuit of “proper body mechanics”
Item from ANVISA’s Resolution No. 63/2011		Unit of analysis	Textual clues/Keywords
Art. 8	VIII. Guidelines for encouraging patient participation in care.	Guidance to encourage the patient to cooperate during movement and transfer, facilitating care and reducing the caregiver’s effort.	Guidance on patient participation
CLT Provision		Unit of analysis	Textual clues/Keywords
Art. 198	The maximum weight that an employee may lift individually is 60 kg (sixty kilograms), subject to special provisions regarding the employment of minors and women.	Prohibition on the transport of individuals or cargo weighing more than 60 kg.	Weight; cargo; individual limit, kg
Art. 390	An employer is prohibited from employing a woman in work that requires the use of muscular strength exceeding 20 (twenty) kilograms for continuous work, or 25 (twenty-five) kilograms for occasional work.	Prohibition on the employment of women in the continuous handling of patients or bodies weighing more than 20 kg, or in the occasional handling of loads weighing more than 25 kg.	Weight; load; limit, kg, women, female

• * Regulatory provisions of Regulatory Standards 17 and 32, of the Ministry of Labor and Employment, Resolution No. 63/2011 of the Collegiate Board of the National Health Surveillance Agency (ANVISA), and Consolidation of Labor Laws (CLT).

2) Analysis of the material

Identification and processing of the contents of the SOPs

After secondary screening, each SOP was downloaded and properly stored on the Google Drive (Google LLC) online storage platform, version 2024, according to geographic region, and then by the responsible UH. The SOPs were then listed in a MicrosoftExcel spreadsheet²².

Recommendations or guidelines related to the regulatory or legal items listed in Table 2 were identified while reviewing the documents. The SOPs were read and reread on two separate occasions to identify and record research-related content in the data collection table²². There was a seven-day interval between the first and second reviews. The second reading aimed to reduce potential intra-examiner biases and discrepancies between the two evaluation time points.

To ensure the relevance of the text segments extracted, the following criteria were established: 1) A direct and/or specific textual relationship between the recommendation and the regulatory provisions; 2) Non-specific guidance that nonetheless aims to comply with regulatory requirements; 3) Recommendations for assessing risks related to the transport and handling of patients, bodies, equipment, or materials.

3) Data processing and interpretation:

The associations or equivalences of the text segments listed in Table 3 were identified independently by two researchers using a priori criteria in a closed-ended manner, based on previously defined normative requirements¹⁹, which were used to identify the presence of the units of analysis in Table 2.

Table 3
Texts containing the associations or equivalents related to each regulatory item

	Regulatory item	Associated guidelines or equivalents
17.5.1	“The manual handling of loads by a worker whose weight is likely to compromise their health or safety shall not be required or permitted.”
17.5.1.1	“The load carried must be reduced in the case of female workers and minor workers in activities permitted by law.”
17.5.2 (10)	“When lifting, handling, and transporting cargo on an individual and non-occasional basis, the following requirements must be observed: a) The areas for picking up and setting down loads, based on the preliminary ergonomic assessment or the AET, must be organized so that the loads, access points, maneuvering spaces, and heights for picking up and setting down do not require the worker to perform excessive flexion, extension, or rotation of the trunk, or other forced and harmful positions and movements of body segments;”	Raise the bed for the comfort of healthcare professionals (SOP01); Preparing the environment and equipment: Inspect the area and remove any obstacles; Note the arrangement of the furniture; Lower the head of the bed/stretcher when moving a patient into a sitting position (SOP07); Position the transport bed near the operating table, lock the wheels, and adjust the height between the operating table and the bed if necessary (SOP11); Assess the environmental conditions for transporting patients (e.g., risk of exposure to inclement weather, noise levels, vibrations, long distances, floor characteristics such as ramp angles, roughness, and unevenness, appropriate preparation of patients for examinations, conditions affecting the safety of the patient or personnel involved in transport, such as the risk of slipping, and high ergonomic demands (SOP14); Lower the bed to chair height (SOP15); Adjust the height of the bed. Keep the room tidy (SOP16); Organize the room (SOP17); Keep the environment organized (SOP18); Assess potential obstacles in the path (SOP20); Adjust the bed height for the ergonomic safety of healthcare professionals (SOP21); Preparing the environment; Inspect the area and remove any obstacles; note the arrangement of the furniture; lock the wheels of the bed, stretcher, or wheelchair; adjust the bed height to suit the worker and the type of procedure to be performed (SOP32).
17.5.2 (4)	“b) Loads and equipment must be positioned as close as possible to the worker, while leaving sufficient space for the feet, so as to facilitate access, not hinder movement, or pose other risks.”	Always keep the patient as close to you as possible during the transfer; keep your arms and the patient close to your body so that your legs can work more efficiently and to maintain your balance (SOP07); Stand upright next to the bed to work as close as possible to the patient’s body that is to be moved (SOP17); Orderly: Are the beds positioned close enough to the patient and are the brakes engaged? (SOP30); Work as close as possible to the patient’s body (SOP32).
17.5.2.1	“The non-occasional lifting of loads that may compromise the worker’s safety and health is prohibited when the horizontal reach of the handle exceeds 60 cm (sixty centimeters) from the body.”
17.5.3 (1)	“The transport and unloading of materials using the propulsion or traction of mine cars, handcarts, or any other mechanical device must take into account the load, frequency, grip, and distance traveled, so as not to compromise the health or safety of workers.”	Check the condition and operation of the chosen mode of transport: presence and proper functioning of seat belts, operation of side rails, proper movement of the headboard and casters, and operation of safety locks. If the bed is electric, check the operation of the control panel (SOP31).
17.5.4 (7)	“When manually moving and transporting loads on a non-occasional basis, one or more of the following preventive measures must be adopted: a) implement technical aids”	With the assistance of two professionals, one on each side of the bed, using the sliding sheet, move the patient on the bed to the side opposite the position to be assumed (SOP01); Check the condition of the stretcher (SOP04); Activate the electronic control to lower the bed to an ideal height that allows the patient to sit up comfortably and easily. If necessary, place the step stool next to the bed. - Lock the chair’s wheels or ask for help to hold it in place, raise the footrest, and remove the armrest (when possible) - (SOP15); Adjust the patient’s height and position using the sliding sheet (SOP17); Provide the necessary equipment for care during transport (SOP20); If the patient does not have effective trunk control, give preference to transport on a stretcher or use a safety harness to secure their trunk in the chair (SOP26);
17.5.4 (3)	“b) adjust the weight and size of the load (dimensions and shape) so that they do not cause an increase in physical exertion that could compromise the worker’s safety and health”	When moving the patient, assess their physical characteristics (weight, height, age, physical limitations, and abilities) - (SOP01); Assess the weight of equipment (SOP14). Exercise extra caution when transporting obese, elderly, premature, polytraumatized, and sedated patients (SOP20).
17.5.4 (1)	“c) limit the duration, frequency, and number of movements to be performed by workers”	Estimate the time required to reach the destination (SOP20).
17.5.4 (1)	“d) reduce the distances to be traveled with loads, where applicable”	Estimate the distance to be traveled (SOP20).
17.5.4	“e) alternate with other activities or sufficient breaks, between periods not exceeding two hours.”
17.5.5 (2)	“Every worker assigned to the non-occasional manual handling of loads must receive instruction on methods for lifting, loading, and unloading loads.”	The nurse must: Train the nursing staff (SOP29); Training: The multidisciplinary team (physician, nurse, nursing technician, physical therapist, and orderly) must stay up to date and be trained to handle the equipment required during transport (SOP30).
32.10.10 (15)	“In patient handling and transport procedures, priority should be given to the use of devices that minimize the effort required of workers.”	Provide the necessary human and material resources, ensuring safety for both parties (SOP01); Ideally, transfer the patient with the assistance of another professional (SOP07); Request assistance from other professionals to transfer the patient from the operating table to the transport stretcher, as needed (SOP11); Request assistance from a colleague on duty if necessary (SOP15); Request assistance from another professional if the patient is frail, overweight, or has difficulty walking (SOP16); Always ask for help when moving an obese patient or one with a high degree of dependency (SOP17); Request assistance from another professional if necessary (SOP18); Designate the nursing professional(s) who will assist the patient during transport (SOP20); It is permitted to request the assistance of a stretcher attendant to help move the transport bed to the transport unit, provided that a member of the nursing staff is present (SOP22); Request the presence of a stretcher attendant for patient transport. When transferring a patient between a stretcher, bed, crib, or incubator, ensure that a sufficient number of staff members are present to guarantee the safety and effectiveness of the maneuver (SOP23); Minimum staffing requirements, based on the transport risk classification: Low Risk: Nursing Technician/Assistant; Medium Risk: Nursing Technician/Assistant, Nurse, or Physician; High Risk: Nurse, Nursing Technician, Physician, and Physical Therapist (SOP27); Escort the patient to the ambulance, together with the team and the stretcher bearer; Accompany the patient during medium- and high-risk transport, with other members of the multidisciplinary team present during the transport (SOP29); Verbally confirm with the Multidisciplinary Team that they are ready for the bed-to-bed transfer (Ask in a clear and firm tone: “Is everyone ready for the bed-to-bed transfer?”); Verify the team’s readiness through verbal confirmation—all members of the multidisciplinary team respond “yes”—and visual confirmation (visually confirm that all members of the multidisciplinary team are properly positioned around the bed). The number of team members required for transport varies according to the severity and complexity of the patient’s clinical condition and, consequently, how critical the transport is considered to be. Accompany the patient to the ambulance together with the team and stretcher bearer (SOP30); - Handle the patient with the assistance of at least two people. Request additional assistance. Team preparation (SOP32); - The number and categories of professionals involved in intra- and extra-hospital transport will vary according to the patient’s clinical condition, weight, and the number and complexity of invasive devices and equipment used (SOP33).
32.10.12 (4)	“Healthcare workers must be: a) trained to use proper body mechanics when moving patients or materials, in order to protect their health and physical well-being”	Useful tips for patient transfers: Keep your feet apart and flat on the floor; Perform transfers safely and calmly; Keep your back straight whenever possible; Use your body weight as a counterbalance to the patient’s; Bend your knees instead of bending your spine; Use synchronized movements; Wear a uniform that allows for freedom of movement and appropriate, well-tied shoes. Avoid trunk rotations and lateral bends (SOP07); Pay attention to ergonomics and safety when moving the patient by following these steps: Plan the movement before performing it; Bend your knees and stand with your feet slightly apart; Use firm, controlled movements, using your entire hand rather than just your fingertips. Place one hand on the patient’s shoulder and the other on the back of their knee. Use your body weight to counterbalance the patient. Use synchronized movements (SOP17); Pay attention to the caregiver’s posture when positioning patients (SOP21); Keep feet apart and fully supported on the floor; use body weight as a counterbalance to the patient’s weight; bend the knees instead of bending the spine (SOP32).
Item from ANVISA RDC No. 63/2011
Art. 8 (7)	VIII. Guidelines to encourage patient participation in the care provided.	Ask the patient to lean their torso forward. When beginning the transfer, check whether the patient is able to assist with the requested posture. Use verbal cues, instructing the patient to bend their knees while keeping their feet on the bed, and then let their legs “roll” to the side, separating the upper and lower body (SOP07); Inform the patient and/or companion about the procedure to be performed and obtain their consent and cooperation (SOP15); Inform the patient and/or companion about the importance of the procedure to be performed, how they can cooperate, and obtain consent (SOP17); Inform the patient and/or companion about the procedure to be performed and obtain their consent and cooperation (SOP18); Ask the patient to sit in the wheelchair or lie down on the stretcher, provided there are no restrictions, or assist them in moving (SOP26); For patients with preserved mobility and no contraindications to exertion, instruct the patient to move slowly toward the transport stretcher, paying attention to the devices in use (SOP30); It is important to explain to the patient and/or caregiver how the patient will be moved, how they can cooperate, where the patient will be taken, and the reason for the transfer. If possible, the patient should be encouraged to assist (SOP32).
CLT Provision
Art. 198	The maximum weight that an employee may lift individually is 60 kg (sixty kilograms), subject to special provisions regarding the employment of minors and women.
Art. 390	An employer is prohibited from employing a woman in work that requires the use of muscular force exceeding 20 (twenty) kilograms for continuous work, or 25 (twenty-five) kilograms for occasional work.
	Total of associations or equivalents	55

For the final coding of the text excerpts recorded in Table 3 (indexing), the researcher triangulation method was used to maximize the reliability of the findings. After individual data collection, the associations and equivalences were compared to reach a joint decision.

Results

Analysis of the textual data identified 55 associations or equivalencies distributed across 20 SOPs. This shows that 60.6% of the analyzed documents (33 SOPs), related to patient transport and transfer, contained at least one item associated with the evaluated requirements. The SOP of a hospital in the Southeast region had the highest coverage of regulatory requirements, with six items (17.5.1 | 17.5.2 a | 17.5.3 | 17.5.4 a | 17.5.4 b | 32.10.10). Table 3 presents the number of associations or equivalences for each regulatory requirement in the analysis of the 33 SOPs in the study.

Guidance on teamwork to reduce the physical effort required of workers (32.10.10 – “device to minimize effort”) was found in 15 SOPs. On the other hand, no SOP provided guidance regarding weight limits or horizontal reach for individual lifting, nor did any include criteria for women’s work, as required by law. Other omissions in the procedures were related to information on duration, frequency, distances to be covered, rotation of activities, or breaks. Four SOPs provided guidance on “proper body mechanics” with recommendations for body positioning and movements to be performed by the professional during patient transfers or transport. Guidelines for patient involvement during the transport and transfer process, in accordance with ANVISA’s recommendation, were found in seven (21.2%) SOPs. Recommendations for better organization of workplaces were found in ten operational procedures, while guidance on positioning patients as close as possible to workers was found in four SOPs.

Discussion

The content analysis sought to infer meanings related to ergonomic recommendations prescribed directly or indirectly in the SOPs. In other words, the study sought explicit and implicit information that is not directly stated but can be inferred from textual clues. According to Bardin¹⁹(2011, p. 143): “Association (element a appears with element b) and equivalence (element a or element d appear in an identical context. Perhaps one can infer a character of equivalence or substitution).”

The low number of associations or equivalencies found in this study indicated low regulatory compliance and uniformity of standard operating procedures (SOPs) related to the transport and manual handling of patients in federal UHs. This finding takes on particular relevance when considering that factors associated with working conditions, as well as the performance of repetitive and physically demanding movements, accounted for 52.44% of the 26,929 workplace accidents recorded among nursing professionals between January 2014 and May 2025⁷. Of the total 14,122 incidents linked to these causes, there was a significant predominance among female workers, who accounted for 84.22% of the records during the analyzed period⁷.

The use of protocols is useful “to ensure compliance with regulatory standards and legal requirements” (p. 70)²³. In addition, it allows for the systematic collection of information during a preliminary ergonomic assessment or ergonomic job analysis. This practice can serve as a starting point for identifying and reducing the gap between the prescribed work and the actual work¹⁷.

The Regulatory Impact Analysis of NR-17 demonstrated the role of ergonomic factors in the occurrence of workplace accidents. Between 2016 and 2020, Labor Inspectors conducted 7,676 analyses of fatal, serious, and minor accidents, of which 66% (5,068 cases) were related to ergonomic causal factors²⁴. This document highlighted several irregularities related to the manual handling of loads, such as: 1) allowing the manual handling of loads whose weight is likely to compromise the worker’s health or safety; 2) failing to adequately train or instruct workers assigned to manual cargo handling regarding work methods; and 3) failing to use appropriate technical means to limit or facilitate manual cargo handling²⁴. For this reason, a detailed analysis within healthcare services is essential for promoting a safety culture among healthcare professionals.

Despite the description of assistive devices, such as height-adjustable stretchers, patient lifts, and slings, there was a lack of specific guidelines for the use of mechanical devices in patient handling. The benefits of using assistive devices are well documented in the literature and are strongly recommended for routine use in healthcare settings when moving patients, as they minimize muscular effort²⁵.

Guidelines for task division during patient handling were found; however, this section does not provide specific details regarding the conditions that would justify such division, limiting itself to a subjective assessment by the team responsible for handling. The recommendation to divide tasks based on the patient’s weight was found in only three SOPs. On the other hand, the recommendations did not mention the weight limit that each worker should handle.

The assessment of the patient’s physical dependence was addressed in the evaluation of the item regarding the division of tasks and encouraging the patient to assist with their own mobility. Both items are directly related, since the patient’s active participation reduces the number of staff required for mobility assistance. Encouraging the patient’s active participation in their own mobility is consistent with training programs aimed at increasing upper limb strength to enhance physical independence and improve patients’ mobility²⁶.

Compliance with the provision addressing horizontal reach exceeding 60 centimeters, together with hospitals’ compliance with section 17.5.1 of NR-17, ensures the conditions established and widely promoted by the National Institute for Occupational Safety and Health²⁷, considering safe weight limits and horizontal reach²⁸.

The small number of SOPs that mentioned mandatory training on cargo handling methods indicates low participation in training initiatives. This situation was also observed in studies that evaluated the implementation of continuing education programs based on NR-32²⁹.

No guidance was found in the SOPs regarding the division of tasks or restrictions on physical exertion specifically for female workers, even considering the predominance of women in the healthcare workforce³⁰, especially in UHs³¹. This lack of recommendations contradicts the requirements set forth in NR-17. The weight limit defined by the CLT could be used as one of the criteria for how the task is performed and organized, with human resources and equipment scaled to meet work demands and conditions. This strategy is one of the preventive measures provided by NR-17 for situations requiring excessive use of muscular strength³. It is known that a worker may use different operational methods to perform the same task³². The way in which they will carry out what has been prescribed will depend on their skills, the existing variables, and their physical, cognitive, and psychological state. From this perspective, SOPs must provide clear guidelines for contexts with diverse and complex requirements. In any case, even with all the rules clearly defined, organizations will not be able to ensure that these are fully implemented, as the gap between what is prescribed and reality will always exist. In this scenario, regulatory strategies are needed that incorporate biomechanical principles for the development of activities, allowing for flexibility to ensure comfort, safety, health, and efficiency for workers. Therefore, an ergonomic approach must prescribe work in a way that anticipates operational modes in different contexts³².

In this way, it becomes possible to bridge the gap between the work prescribed by the organization - that is, what management expects - and the way in which the work is actually understood and performed by employees. Conversely, absent, generic, or vague guidelines tend to widen this gap, leading to differing interpretations of tasks and the adoption of practices that differ from those initially outlined in the prescribed work.

Patient safety in the hospital setting is closely linked to the level of development of the institutional safety culture adopted by the hospital organization³³. The analysis allows for an exploration of the systemic causes of accidents, focusing on the organizational dimension and the work context³⁴. Thus, based on the classification of safety culture levels, the inadequacy of the SOPs fell below the primary level of the classification, the pathological level³⁵. At this level, managers implement only what is mandatory³⁴.

The EBSERH Quality Management Program, as a system for the periodic assessment of services provided at university hospitals, includes a requirements manual based on legislation and regulations applicable to health services³⁶. Thus, the EBSERH Quality Management Program Requirements Manual³⁶ should be updated to include specific items related to the movement and transport of patients.

In addition to complying with the standards mentioned above, hospital SOPs can be aligned with ABNT ISO/TR 12.296/2024³⁷. This standard provides technical guidelines that can supplement the regulations discussed in this study, as well as risk management tools for patient transport.

Risk management during patient handling - based on the development of protocols, standards, and routines, the standardization of tasks, and the use of appropriate equipment, combined with an ergonomics program - has the potential to reduce illness and the resulting absenteeism in Brazilian hospitals³⁸. Thus, the implementation of ABNT ISO/TR 12.296/2024 goes beyond regulatory compliance, establishing itself as a strategic tool for improving quality of life and workplace safety in hospital care, aligning the activities of university hospitals with international best practices.

Despite the existence of a comprehensive regulatory framework and federal guidelines designed to support the adoption and implementation of health technologies within the SUS, there is a significant weakness related to the lack of methodological standardization and specific regulatory instruments aimed at operationalizing this process. The findings show that there are no structured documents specifically designed to guide the practical stages of technology implementation, which results in procedural heterogeneity and technical-operational uncertainty across different institutional contexts.

In other words, although general public policy guidelines exist, there are still no sufficiently clear parameters regarding the methods, workflows, and strategies that should guide the practical execution of implementation routines³⁹. The development of standard procedures must adhere to the principles of legality, prevention, and institutional accountability, which are fundamental to the implementation of good ergonomics practices².

The results of this study cannot be generalized⁴⁰to the entire Brazilian hospital network, given the diversity of existing administrative structures, including philanthropic, municipal, state, and private institutions. However, the findings are scientifically relevant as they highlight inconsistencies in the SOPs analyzed, as well as weaknesses related to their content validity, particularly regarding the consistency, clarity, and normative and technical-scientific adequacy of the guidelines presented.

The method used did not analyze the structural causes of the inadequacies in the SOPs, which opens the door to future, more comprehensive investigations that expand the scope of the analysis to include other hospitals. In addition, ergonomic analyses are needed to systematically observe the work performed by professionals to identify the gap between the prescribed and actual work. Although the study’s results cannot be generalized, it is possible to suggest the use of this type of method for data collection in preliminary ergonomic assessments and/or ergonomic work analyses. The results highlight the importance of initiatives that promote the standardization of hospital activities, in compliance with laws and regulations, aiming for greater safety and efficiency in the processes of patient handling in the UHs administered by EBSERH.

Conclusion

The study identified inconsistencies in the content of the SOPs and failures to comply with regulatory and legal requirements related to the transport and handling of patients. The analysis also revealed that hospitals do not follow the technical guidelines recommended by current regulations. The lack of alignment between the SOPs and occupational safety and health laws and regulations may compromise workers’ health and the quality of patient handling. Thus, a safety culture regarding patient handling is absent in these hospitals, as they do not meet legal requirements in their prescribed procedures. Therefore, changes are needed in the prescribed processes, involving multidisciplinary validation and the application of biomechanical knowledge combined with workers’ practical experience.

Given the results obtained, it can be concluded that the study contributed to the fields of hospital ergonomics and occupational health by highlighting gaps in the SOPs and in the implementation of health and safety standards by UHs. This evidence serves as a warning of the need for more effective public policies and guidelines to ensure that patient transport activities comply with Brazilian laws and regulations applicable to the hospital workplace.

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• Information on academic work:
  This article is based on the final course project by Geyson Fernando de Lima Batista, titled “Conformidade dos procedimentos operacionais padrão para movimentação de pacientes em hospitais universitários: avaliação do trabalho prescrito (Compliance with Standard Operating Procedures for Patient Handling in University Hospitals: An Evaluation of Prescribed Work)”, presented at the Department of Physical Therapy at the Federal University of Juiz de Fora, Governador Valadares Campus, on March 10, 2025.
• Data availability:
  The data are available on SciELO Data: Batista GFL, Andrade PMO. Conformidade dos Procedimentos Operacionais Padrão para Movimentação de Pacientes em Hospitais Universitários: Avaliação do Trabalho Prescrito [Internet]. SciELO Data; 2026. Available from: https://doi.org/10.48331/scielodata.QZGGNR
• Statement on the use of Artificial Intelligence:
  The authors declare that no artificial intelligence tools were used in the preparation of this article.
• Presentation at a scientific event:
  The authors report that the study has not been presented at a scientific event.
• Funding:
  The authors declare that the study was not subsidized.

Edited by

• Responsible editors:
  Eduardo Algranti https://orcid.org/0000-0002-6908-7242 Fundação Jorge Duprat Figueiredo de Segurança e Medicina do Trabalho – FUNDACENTRO
  Maria Helena Palucci Marziale https://orcid.org/0000-0003-2790-3333 Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto – EERP/USP

Data availability

The data are available on SciELO Data: Batista GFL, Andrade PMO. Conformidade dos Procedimentos Operacionais Padrão para Movimentação de Pacientes em Hospitais Universitários: Avaliação do Trabalho Prescrito [Internet]. SciELO Data; 2026. Available from: https://doi.org/10.48331/scielodata.QZGGNR

Publication Dates

• Publication in this collection
  14 Aug 2026
• Date of issue
  2026

History

• Received
  18 Mar 2025
• Reviewed
  09 Oct 2025
• Accepted
  24 Mar 2026