PROFESSIONAL

Manual handling: the challenges

of different care environments
Jacqueline Johnstone

suffered lower back pain (Van Hoof et al, 2018), MSDs affect all
ABSTRACT muscles, joints and tendons of the body and manifest as lower
Work-related musculoskeletal disorders (WRMSDs) continue to be a problem back pain, shoulder pain, neck pain (with or without headaches),
in the health and social care setting, despite staff receiving mandatory and upper and lower limb discomfort.Types of MSD presenting
manual handling training for many decades. The author discusses WRMSDs, in the general population are now categorised by specific parts
with a focus on various nursing roles. The principle of manual handling of the body (HSE, 2019a) as detailed in Table 1.
as solely ‘person moving’ or ‘transferring’ is challenged because a range MSDs resulted in 6.9 million working days lost in the
of activities can cause musculoskeletal problems. The legislation and working population of Britain in 2018–2019 (HSE, 2019a).
regulations are explored in relation to practice. The benefits of introducing a This is a slight rise from the 2017-2018 figure but a reduction
specific risk-assessment tool designed for nurses working in neonatal wards from the 2016-2017 figure, when 8.9 million days were lost
is discussed. (HSE, 2017a).This may reflect the success of legislation, manual-
Key words: Back pain ■ Risk assessment ■ Stress ■ Work-related handling training and availability of equipment or this may
musculoskeletal disorders ■ Manual handling reflect the move from hospital-based care to community and
self-care independence.

A
Many of these lost working days may not be attributed to
ccording to the European Agency for Safety a specific work-related episode. The records only detail the
and Health at Work (2020) work-related low reason and number of sick days, but MSDs can be exacerbated
back pain and injuries are among of the most by work tasks, as well as by personal activities and daily routines.
common musculoskeletal disorders caused by Furthermore, the recorded statistics do not include staff who do
manual handling. not take time off work; for example, those who work long shifts
Back pain in staff working in the health sector has been a and may have twinges, aches and pains, but then have 4 days
long-standing problem (Health and Safety Executive (HSE), off rota, during which they can recover (Ribeiro et al, 2017).
2019a). Over the years, trusts have employed various manual- As well as the impact these lost days have on health, they
handling training schemes, and made equipment available to potentially amount to additional costs for the trust from the
assist staff, carers and patients during manual-handling tasks. employment of agency staff, bed closures, cancelled procedures,
Equipment such as hoists is now commonplace in care settings, reductions in services and care, as well as a possible increase in
both in hospital and community settings (Davis and Kotowski, staff stress and workload. It is important to acknowledge that
2015). Despite this, musculoskeletal disorders (MSDs), including the statistics from the HSE, detailed previously, relate to workers
work-related musculoskeletal disorders (WRMSDs), continue in health and social care settings and do not sub-categorise into
to be a problem (Ribeiro et al, 2017). occupation or roles within this setting. This does not alter the
impact MSD can have on patient care and the healthcare team.
WRMSD instances and impact on care The effect of a member of the team being off work due to
Health and social care work settings have higher than average a WRMSD may have a significant impact on patient care, for
reported instances of MSDs, with more than 1400 instances example, in reduced or delayed services. The impact on other
per 100 000 employees (HSE, 2019a). Only construction and individuals in the care pathway should also be acknowledged.
the combined agriculture, forestry and fishing industries have Staff may have to work additional hours to cover for the sick
higher rates (HSE, 2019a). Although nurses have historically employee, while others may have to spend longer with patients
who are upset because there will be a delay in their waiting time
or test results. Caine (2015) identified the effects that sickness
and worker absence can have on the work environment and
© 2020 MA Healthcare Ltd

Jacqueline Johnstone, was a Lecturer at Queen’s University

Belfast, at the time of writing. She is now a Lecturer in Nursing team.Alongside the cost factors, the effects on clients’ satisfaction
and Community Health, Glasgow Caledonian University, levels and staff wellbeing and pleasure in work were identified
[email protected] and these can lead to further staff sickness.Work-related stress,
Accepted for publication: October 2019 anxiety or depression now equates to 54% of the working
days lost (HSE, 2019b), therefore factors that can impact on

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 PROFESSIONAL

Box 1. Manual handling: points to consider Table 1. Work-related musculoskeletal disorders by anatomical site in the
general population reported to the THOR-GP scheme 2013-2015
Manual handling is the transportation of a load by bodily force:
lifting, putting down, pushing, pulling, carrying and moving. It is Anatomical site Percentage reported
the method used to do the activity which carries the risk
Lumbar spine/trunk 25−30%
There is a common myth that if there is no lifting or moving of
a patient then no manual handling is taking place and there is Hand/wrist/arm 20−25%
no risk. This is false. Think about some of the routine actions Shoulder 10−15%
performed during a working day such as attaching infusion
pumps to drip stands and docking stations; assisting a patient Hip/knee 10−15%
with oral hygiene needs; completing a dressing change or skin
care assessment; helping a patient to dress; or assisting new Neck and thoracic spine 5−10%
mothers to establish breastfeeding
Elbow 5−10%
Consider and reflect
Ankle/foot 5−10%
Does the technique involve:
Other 0−5%
■■ Bending/slouching/stooping?
■■ Twisting rather than turning? Source: adapted from Health and Safety Executive, 2019a
■■ Bending and twisting?
■■ Twisting and stretching?

Are these positions being maintained for any length of time? the working environment, like WRMSD sick days, need to be
Are these positions repeated throughout the day without addressed and it may not be productive to consider one factor in
sufficient rest times? isolation.The prevalence rate for work-related stress, depression
or anxiety among human health and social work activities was
Consider and reflect
2120 per 100 000 people employed over 12 months, averaged
Think about a routine task in your role: over the period 2016–2017 to 2018–2019 (HSE, 2019b).
■■ Does the task involve any of the above risks?
■■ What is your posture like while doing the task?
■■ Is your posture fixed?
‘Workplace psychosocial factors such as
■■ Is there space to complete the task? organisational culture, the health and safety
climate and human factors may create the
Can you make adjustments to your routine or the task to try to
reduce the risks?
conditions for WRMSDs to occur. Generally, none
of these factors acts separately to cause WRMSDs.
Remember They more commonly occur as a result of a
Even the simplest daily task ■■ Getting in and out of combination and interaction among them.’
can be a risk and can lead to a car HSE, 2019a: 3
or aggravate a musculoskeletal ■■ Typing on a keypad/
disorder, including: keyboard
WRMSDs may be the result of an isolated episode at work,
■■ Tying shoelaces ■■ Carrying handbags or
■■ Ironing shoulder bags for example an injury following a fall, or may occur as a result
■■ Emptying or filling the ■■ Pushing a shopping of long-term activity and can be chronic and life impacting
dishwasher and/or washing trolley (HSE, 2019a).Work-related incidents can be difficult to prove
machine as the source of the MSD, as poor posture and bad practices
Training: consider and reflect may be prevalent in the home and personal life of the individual
(Johnstone and Owen, 2017). Manual-handling training may
■■ What type of training have you received—workshop, online,
only focus on work tasks rather than lifestyle changes and
simulation?
■■ Was the training specific to your role? an accumulation of trauma and poor practices can be further
■■ How have you adapted the way you work in response to the exacerbated by work tasks (Murphey, 2018).
training?
■■ Did the training cause you to make changes to your working or
The manual handling myth
home life and to back and limb care?
■■ Which manual-handling tools do you use in your current role?
Some of the literature still refers to injuries being sustained
■■ Are these tools specific to your role? through:
■■ How often are manual handling assessment tools
completed? ‘Poor practice in manual handling—from
Moving and handling patients: consider and reflect
moving equipment, laundry, catering, supplies,
waste, refuse, etc to assisting people to move.’
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Think about assisting a patient from bed to chair: HSE, 2014

■■ Is there a specific risk assessment for this task?
■■ What are the manual-handling risks associated with this task?
An increasing number of injuries may be sustained through
■■ Is there equipment available to reduce the risks associated
with this task? years of repetitive tasks involving twisting, bending, stooping and
stretching or long periods staying in fixed positions (Johnstone

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PROFESSIONAL

Table 2. Legislation and guidance associated with manual handling

there are limited devices and MSD remains a
potential risk for children’s nurses, midwives and
Act relating to manual handling other neonatal staff. The risk in these specialties
Health and Safety at Work Act 1974 is often viewed as less as the load is “small”.’
Johnstone and Owen, 2017: 290
Regulations and guidelines on manual handling

Management of Manual Handling Provision and Use Lifting Operations These challenges may be similar for the nurse working in
Health and Safety Operations of Work Equipment and Lifting the home and community setting, with staff ‘hunching’ over the
at Work, 1992 Regulations,1992 Regulations Equipment electronic tablet updating or reviewing the patient record or
(MHOR, 1992) (PUWER), 1998 Regulations
(LOLER), 1998
bending in a confined space to sample blood from a patient in
their bed.The community midwife supporting the mother with
breastfeeding or performing maternal or newborn assessments,
Table 3. Manual Handling Operations Regulations, 1992 may need to ‘stoop’ and ‘twist’ to complete the task.As previously
Duty of employer Duty of employee
highlighted, it is the repetitiveness and strains on posture—for
example, twisting at the waist rather than pivoting the entire
■■ AVOID manual handling tasks if ■■ Use any systems of work provided by body round—that can cause WRMSDs. Box 1 includes some
possible the employer
■■ ASSESS any residual risk ■■ Use appropriate equipment provided
points to consider on manual handling in practice.
■■ REDUCE the risk to lowest level— ■■ Co-operate with the employer and take
redesign tasks, provide equipment, care of self and others Manual handling training: fit for purpose?
distribute tasks, rotate staff, allow ■■ Exercise the right to refuse to carry The introduction of the Health and Safety at Work Act 1974
sufficient rest out a task if no safe system of work started the process for ensuring all aspects of safety in the
■■ INFORM employees about loads in place
■■ REVIEW the risk assessment as
workplace. This was followed up with further guidelines and
necessary regulations around manual handling and lifting equipment,
as detailed in Table 2. The Manual Handling Operations
Source: adapted from Manual Handling Operations Regulations (1992)
Regulations (MHOR) (1992) (Table 3) detail the duties of the
employer and also the employee with regards to manual handling.
Under MHOR (1992) the employer should: ‘avoid,
and Owen, 2017). These musculoskeletal actions are rarely assess reduce and inform’ around risk. The employee has a
done in isolation and often fixed positions or static work and responsibility to work with the employer to ensure safe systems
movement (dynamic work) are part of the same task, for example are in place (MHOR, 1992).This includes identifying risk and
transferring a sick infant from a cot into his or her parent’s arms using the systems and equipment provided by the employer
(Johnstone and Owen, 2017), assisting a breastfeeding mother, and also to inform the employer of any perceived risks and
carrying out suture removal or a dressing change. Environmental concerns. These duties rely on risks being identified, and in
factors may also influence the activity—for example, where turn this identification of risk is dependent on the focus of
there is limited space, staff may twist rather than pivot or step the employee’s manual-handling training experience, as well
to turn (Johnstone and Owen, 2017). as previous experience or exposure to risk. Staff may not be
As the industry with the third greatest number of days lost aware that repetitive fixed positions can have an adverse impact
due to WRMSDs, the health sector needs to continually monitor on the musculoskeletal system and could lead to a WRMSD.
and minimise the risk of MSDs to staff, patients and carers There is no set format for manual-handling training; those
(HSE, 2019b). In addition, as clinical tasks change in nursing staff who have worked in a variety of care settings will have
and midwifery practice (Nursing and Midwifery Council, 2018), experience of various types of training, either face to face or
nurses should be aware of the impact that ‘new roles’ and new online (National Back Exchange, 2010). The European Panel
technologies may have on their musculoskeletal system. For on Patient Handling Ergonomics (EPPHE) identified enduring
example, the increase in healthcare areas using tablets to input complications and hurdles to introducing a manual-handling
patient observations and to maintain electronic records.These directive for patient handling (Hignett et al, 2014). This is a
tasks may require repetitive positions and may involve ‘hunching’ concern given that our knowledge of WRMSDs supports
over the screen and could lead to neck, shoulder, arm and the principle of manual handling and safe practice as being
hand WRMSDs. These injuries are already commonplace for more than just patient moving. It involves repetition and fixed
some health professionals, notably sonographers (Murphey, positions along with bending and twisting. The barriers to
2018). Although sonographic equipment has improved, the implementing the directive were identified as being:
repetitiveness of the role continues, as does the repetitiveness
within other healthcare roles, for example, phlebotomy. Johnstone ‘A lack of scientific evidence (including
© 2020 MA Healthcare Ltd

and Owen (2017) highlighted the specific manual-handling ergonomic standards) for specific patient
challenges faced in paediatric and neonatal environments: handling techniques and equipment; a lack of
standards for educational programmes including
‘Although there are tools and aids to reduce the inter-agency interfaces for staff training.’
risks within adult and plus size environments Hignett et al, 2014: 191

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There is a responsibility for staff to reduce the risk as far Table 4. The TILEEO tool
as ‘reasonably practical’. However, education and knowledge
about the risks of manual handling and this notion of ‘reduced TILEEO
risk’ continues to be a problem in many health and social care
environments.The same minimisation or avoidance of the notion T Task Does the Task involve:
Twisting
of risk may also apply to nurses and other health professionals Stooping
working in the community setting. Much community work may Reaching
involve transferring patients and equipment may be available
Static holds
for this. However, King et al (2018) highlighted the issues faced
Frequency
by staff in the home care setting, specifically the bathroom:
Pushing

‘Small restrictive spaces, a poor fit between Pulling

available equipment and the environment, Lifting
a reliance on manual handling techniques Carrying
(but insufficient space to use optimal body Or a combination of these?
mechanics), attempts to maintain normalcy, and
caring for unsteady and unpredictable clients.’ I Individual Is training required?
Is the individual pregnant?
King et al, 2018: 493
Do they have a pre-existing condition or injury?
Would their height affect the ability
Although equipment and space may not be an issue, not all to complete the task, i.e. stooping or
manoeuvres can be supported fully with mechanical assistance reaching up?
(King et al, 2018). These issues may not be fully addressed
in eLearning moving-and-handling packages or within the L Load Is this a—
Heavy
time constraints of a face-to-face training day. Despite this, the
employer could still have fulfilled their duty under MHOR Bulky
(1992). They have trained staff to avoid and assess the risk, as Awkward to hold/grasp
well as providing equipment and allowing sufficient rest. Staff, Unstable
by participating in the training, are informed about loads and Dangerous
their duty as employees to report a risk and request an assessment —Load?
from the back care adviser/manual handling lead as required.
Although not all tasks can be supported with equipment and E Environment Space constraints?
Slippery/uneven surface?
elements of bending, twisting and stretching are unavoidable, the
Steps?
back care adviser can advise on how to reduce the risk. Staff,
Poor lighting?
however, may not contact the back care adviser for all tasks.
Temperature and climate fluctuations?

No risk assessment tool means no risk? Angles, narrow spaces or obstacles?

To accompany manual-handling training, there is now a
growing number of manual-handling patient risk-assessment E Equipment Is there equipment available to assist with
the task?
tools available for employers to introduce and employees
to complete in the care environment. The HSE Health and O Other Is the client attached to equipment which may
increase the risk?
Safety Laboratory (Pinder, 2002) explored some of these Are there additional people who can assist?
tools, comparing various features of each. These features Could the task be modified without
included: injury focus, load/force, lift and distance, flexion and compromising the care?
symmetry, frequency and factor interaction. Few tools actually Patient/client concerns
addressed all of these issues and there were wide discrepancies
Source: adapted from WorksafeUK (2018) and HSE (2019c)
between the scoring systems (Pinder, 2002). Some of these
tools required mathematical equations or ‘look up’ tables and
posture codes. Posture codes, such as the example provided Environment and Other) has been amended and sometimes
by Pinder (2002) from the Ovako Working posture Analysis referred to as TILEEO (Task, Individual, Load, Environment,
System (OWAS) have a user-friendly appeal, requiring the Equipment and Other) (Table 4). This can be an easy tool
individual to consider back, arms and leg position/posture to remember, however the ‘load’ focus can be seen as only
as well as load for the activity. This is then categorised, and pertinent to a lifting task and the task requires the individual
© 2020 MA Healthcare Ltd

the user is directed to actions to be followed. It is important to be aware of the risk involved, for example, in bending or
for staff to feel that a tool is easy to use and does not require twisting.
input from an ergonomist for every activity. MHOR (1992) In the neonatal and infant care units of one trust, the lack of
highlights TILEO as a risk tool, but this is not considered in user-friendly risk-assessment tools, as detailed by clinical staff,
the HSE review (Pinder, 2002).TILEO (Task, Individual, Load, and the lack of equipment suitable for the tasks, with staff also

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Name: Joora Tool [0-12 months]

Hospital Number: Moving and Handling
D.O.B: [Johnstone, Owen and Owen – Version 6]

Affix Patient Label

Score Patient Specific Risks
(re-assess as patient condition changes) Level of Risk to infant and staff (Level as appropriate to age)
HIGH = unable to assist in any way – unable to sit or balance – minimal mobility
MEDIUM = some ability to balance and support weight
Date LOW = able to move independently – requires supervision and guidance

Pt Weight
Artefacts (i.e. chest drains; lines; V.P Physical & Medical Complications
Shunts; ventilated; replogle tube) (i.e. muscle weakness / paralysis; sedation;
fragile skin)
Pt Length
Transferring Patient
Transferring Patient
1 2 3 4 5 6 7 8 9 10 1 – child assisted transfer / appropriate height surface, without space constraints
Low Risk High Risk 5 – transferring high to low / low to high in confined space – causing compromised
Bed Changing posture (stoop / twisting / turning / slips / trips / falls)
10 – as 5 with patient ventilated with other artefacts (see artefacts list box)
1 2 3 4 5 6 7 8 9 10
Low Risk High Risk Bed Changing
Feeding 1 – empty cot (where child sleeps) / variable height
5 – patient in cot / variable height / 1 nurse rolling patient high risk of patient falling
10 – patient in cot / fixed height / 2 nurses
1 2 3 4 5 6 7 8 9 10
Low Risk High Risk
Feeding
Bathing / Hygiene Cares 1 – self feeding
5 – breast / bottle feeding
1 2 3 4 5 6 7 8 9 10 10 – oral / nasogastric /gastrostomy / feeding
Low Risk High Risk
General Mobility Bathing / Hygiene Cares
1 – age appropriate / variable height bath / slip / fall risk
1 2 3 4 5 6 7 8 9 10 5 – bed bath / cares / variable height / slip / fall risk
Low Risk High Risk 10 – bed bath / cares – fixed height / bathing fixed height bath / slip / fall risk
Play / Other
General Mobility
1 – self ventilating / age appropriate mobility / variable height cot
1 2 3 4 5 6 7 8 9 10 5 – non invasive ventilation / variable height cot
Low Risk High Risk
10 – paralysed / fixed height cot
Falls Risk
Play
1 2 3 4 5 6 7 8 9 10 1 – patient paralysed / sedated / restricted activity
Low Risk High Risk 5 – patient confined to variable height cot
Score 10 – floor play / age appropriate / permanent medical complications (see boxes above)
Total
Falls Risk
Level 1 – sedated / unconscious
5 – lively / restless
Sign 10 – parents / carer – asleep whilst holding child (extreme tiredness / alcohol / drugs) /
slip, trip, fall whilst carrying child / cot sides not in place
JJ. KO. Sept ‘12

Figure 2. A section of the JOORA tool for nurses working with children aged 0 to 12 months in neonatal units

reporting that there were limited WRMSD risks in the wards, Conclusion
resulted in the creation of the Johnstone, Owen and Owen The problem of WRMSDs is not unique to the UK; for example,
Risk Assessment (JOORA) for manual handling (Figure 2). Ribeiro et al (2017) reported that 84% of Portuguese nurses
Staff were consulted on the need for a manual-handling risk- reported signs and symptoms of having WRMSDs.Anderson and
assessment tool and the problems with existing assessment tools Oakman (2016) reported that WRMSDs remain problematic for
were discussed. The JOORA tool was developed and after all healthcare workers. It is clear that WRMSDs continue to be
various pilot studies, in a variety of care settings, the tool was problematic for the multidisciplinary team in all care settings.
rolled out Trust wide (Johnstone and Owen, 2017). Before the Johnstone and Owen (2017) demonstrated how a manual-
introduction of the JOORA tool, records showed that manual- handling tool that is specific to the activities and environment
handling risks and details about patient needs were handed over of the role can have a positive impact on staff awareness of
verbally at the bedside by nurses and completion of the previous manual handling and associated risk. Individual workers must
manual-handling tool was sporadic (Johnstone and Owen, 2017). use tools that highlight risk and support the application of safe
The introduction of the JOORA saw an 89% compliance rate manual-handling principles to ensure that the risks in all tasks
and a 53% reduction in inappropriate referrals to the back-care are reduced, alongside using equipment when available. It is
© 2020 MA Healthcare Ltd

adviser (Johnstone and Owen, 2017). Compliance was further through knowing the risks that individuals can consciously take
improved by the introduction of an electronic version for staff actions to reduce them. BJN
working in critical care areas (Johnstone and Owen, 2017).
Figure 2 shows the JOORA tool for use by nurses working
in neonatal units. Declaration of interest: none

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Anderson SP, Oakman J. Allied health professionals and work-related

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2020. https://tinyurl.com/zudg33w (accessed 5 March 2020)
Health and Safety Executive. The Scottish manual handling passport scheme. ■■ The introduction of the a risk-assessment tool in one neonatal unit reduced
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Health and Safety Executive. Work related musculoskeletal disorder statistics
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Health and Safety Executive. Work-related stress, anxiety or depression statistics
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CPD reflective questions

■■ Take time to consider and reflect on the manual-handling training you have received throughout your career. Was it
practical and useful? How has that training altered your practice?
■■ Consider the duties of your employer and your duties under the Manual Handling Operations Regulations (1992).
Reflect on how these are working in practice
■■ Think about some of the routine tasks you and other members of your team perform regularly—what improvements
could be made and would using a moving and handling tool help make them safer?

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