According to the European Agency for Safety and Health at Work (2020) work-related low back pain and injuries are among of the most common musculoskeletal disorders caused by manual handling.
Back pain in staff working in the health sector has been a long-standing problem (Health and Safety Executive (HSE), 2019a). Over the years, trusts have employed various manual-handling training schemes, and made equipment available to assist staff, carers and patients during manual-handling tasks. Equipment such as hoists is now commonplace in care settings, both in hospital and community settings (Davis and Kotowski, 2015). Despite this, musculoskeletal disorders (MSDs), including work-related musculoskeletal disorders (WRMSDs), continue to be a problem (Ribeiro et al, 2017).
WRMSD instances and impact on care
Health and social care work settings have higher than average reported instances of MSDs, with more than 1400 instances per 100 000 employees (HSE, 2019a). Only construction and the combined agriculture, forestry and fishing industries have higher rates (HSE, 2019a). Although nurses have historically suffered lower back pain (Van Hoof et al, 2018), MSDs affect all muscles, joints and tendons of the body and manifest as lower back pain, shoulder pain, neck pain (with or without headaches), and upper and lower limb discomfort. Types of MSD presenting in the general population are now categorised by specific parts of the body (HSE, 2019a) as detailed in Table 1.
| Anatomical site | Percentage reported |
|---|---|
| Lumbar spine/trunk | 25−30% |
| Hand/wrist/arm | 20−25% |
| Shoulder | 10−15% |
| Hip/knee | 10−15% |
| Neck and thoracic spine | 5−10% |
| Elbow | 5−10% |
| Ankle/foot | 5−10% |
| Other | 0−5% |
MSDs resulted in 6.9 million working days lost in the working population of Britain in 2018–2019 (HSE, 2019a). This is a slight rise from the 2017-2018 figure but a reduction from the 2016-2017 figure, when 8.9 million days were lost (HSE, 2017a). This may reflect the success of legislation, manual-handling training and availability of equipment or this may reflect the move from hospital-based care to community and self-care independence.
Many of these lost working days may not be attributed to a specific work-related episode. The records only detail the reason and number of sick days, but MSDs can be exacerbated by work tasks, as well as by personal activities and daily routines. Furthermore, the recorded statistics do not include staff who do not take time off work; for example, those who work long shifts and may have twinges, aches and pains, but then have 4 days off rota, during which they can recover (Ribeiro et al, 2017).
As well as the impact these lost days have on health, they potentially amount to additional costs for the trust from the employment of agency staff, bed closures, cancelled procedures, reductions in services and care, as well as a possible increase in staff stress and workload. It is important to acknowledge that the statistics from the HSE, detailed previously, relate to workers in health and social care settings and do not sub-categorise into occupation or roles within this setting. This does not alter the impact MSD can have on patient care and the healthcare team.
The effect of a member of the team being off work due to a WRMSD may have a significant impact on patient care, for example, in reduced or delayed services. The impact on other individuals in the care pathway should also be acknowledged. Staff may have to work additional hours to cover for the sick 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 team. Alongside the cost factors, the effects on clients' satisfaction levels and staff wellbeing and pleasure in work were identified and these can lead to further staff sickness. Work-related stress, anxiety or depression now equates to 54% of the working days lost (HSE, 2019b), therefore factors that can impact on the working environment, like WRMSD sick days, need to be addressed and it may not be productive to consider one factor in isolation. The prevalence rate for work-related stress, depression or anxiety among human health and social work activities was 2120 per 100 000 people employed over 12 months, averaged over the period 2016–2017 to 2018–2019 (HSE, 2019b).
‘Workplace psychosocial factors such as organisational culture, the health and safety climate and human factors may create the conditions for WRMSDs to occur. Generally, none of these factors acts separately to cause WRMSDs. They more commonly occur as a result of a combination and interaction among them.’
WRMSDs may be the result of an isolated episode at work, for example an injury following a fall, or may occur as a result of long-term activity and can be chronic and life impacting (HSE, 2019a). Work-related incidents can be difficult to prove as the source of the MSD, as poor posture and bad practices may be prevalent in the home and personal life of the individual (Johnstone and Owen, 2017). Manual-handling training may only focus on work tasks rather than lifestyle changes and an accumulation of trauma and poor practices can be further exacerbated by work tasks (Murphey, 2018).
The manual handling myth
Some of the literature still refers to injuries being sustained through:
‘Poor practice in manual handling—from moving equipment, laundry, catering, supplies, waste, refuse, etc to assisting people to move.’
An increasing number of injuries may be sustained through years of repetitive tasks involving twisting, bending, stooping and stretching or long periods staying in fixed positions (Johnstone and Owen, 2017). These musculoskeletal actions are rarely done in isolation and often fixed positions or static work and movement (dynamic work) are part of the same task, for example transferring a sick infant from a cot into his or her parent's arms (Johnstone and Owen, 2017), assisting a breastfeeding mother, carrying out suture removal or a dressing change. Environmental factors may also influence the activity—for example, where there is limited space, staff may twist rather than pivot or step to turn (Johnstone and Owen, 2017).
As the industry with the third greatest number of days lost due to WRMSDs, the health sector needs to continually monitor and minimise the risk of MSDs to staff, patients and carers (HSE, 2019b). In addition, as clinical tasks change in nursing and midwifery practice (Nursing and Midwifery Council, 2018), nurses should be aware of the impact that ‘new roles’ and new technologies may have on their musculoskeletal system. For example, the increase in healthcare areas using tablets to input patient observations and to maintain electronic records. These tasks may require repetitive positions and may involve ‘hunching’ over the screen and could lead to neck, shoulder, arm and hand WRMSDs. These injuries are already commonplace for some health professionals, notably sonographers (Murphey, 2018). Although sonographic equipment has improved, the repetitiveness of the role continues, as does the repetitiveness within other healthcare roles, for example, phlebotomy. Johnstone and Owen (2017) highlighted the specific manual-handling challenges faced in paediatric and neonatal environments:
‘Although there are tools and aids to reduce the risks within adult and plus size environments there are limited devices and MSD remains a potential risk for children's nurses, midwives and other neonatal staff. The risk in these specialties is often viewed as less as the load is “small”.’
These challenges may be similar for the nurse working in the home and community setting, with staff ‘hunching’ over the electronic tablet updating or reviewing the patient record or 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, may need to ‘stoop’ and ‘twist’ to complete the task. As previously highlighted, it is the repetitiveness and strains on posture—for example, twisting at the waist rather than pivoting the entire body round—that can cause WRMSDs. Box 1 includes some points to consider on manual handling in practice.
| Manual handling is the transportation of a load by bodily force: lifting, putting down, pushing, pulling, carrying and moving. It is the method used to do the activity which carries the risk | |
|---|---|
| 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 no risk. This is false. Think about some of the routine actions performed during a working day such as attaching infusion pumps to drip stands and docking stations; assisting a patient with oral hygiene needs; completing a dressing change or skin care assessment; helping a patient to dress; or assisting new mothers to establish breastfeeding | |
| Consider and reflect | |
| Does the technique involve: |
|
| Consider and reflect | |
| Think about a routine task in your role: |
|
| Remember | |
| Even the simplest daily task can be a risk and can lead to or aggravate a musculoskeletal disorder, including: |
|
| Training: consider and reflect | |
|
|
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| Moving and handling patients: consider and reflect | |
| Think about assisting a patient from bed to chair: |
|
Manual handling training: fit for purpose?
The introduction of the Health and Safety at Work Act 1974 started the process for ensuring all aspects of safety in the workplace. This was followed up with further guidelines and regulations around manual handling and lifting equipment, as detailed in Table 2. The Manual Handling Operations Regulations (MHOR) (1992) (Table 3) detail the duties of the employer and also the employee with regards to manual handling.
| Act relating to manual handling | |||
|---|---|---|---|
| Health and Safety at Work Act 1974 | |||
| Regulations and guidelines on manual handling | |||
| Management of Health and Safety at Work, 1992 | Manual Handling Operations Regulations, 1992 (MHOR, 1992) | Provision and Use of Work Equipment Regulations (PUWER), 1998 | Lifting Operations and Lifting Equipment Regulations (LOLER), 1998 |
| Duty of employer | Duty of employee |
|---|---|
|
|
|
Under MHOR (1992) the employer should: ‘avoid, assess reduce and inform’ around risk. The employee has a responsibility to work with the employer to ensure safe systems are in place (MHOR, 1992). This includes identifying risk and using the systems and equipment provided by the employer and also to inform the employer of any perceived risks and concerns. These duties rely on risks being identified, and in turn this identification of risk is dependent on the focus of the employee's manual-handling training experience, as well as previous experience or exposure to risk. Staff may not be aware that repetitive fixed positions can have an adverse impact on the musculoskeletal system and could lead to a WRMSD.
There is no set format for manual-handling training; those staff who have worked in a variety of care settings will have experience of various types of training, either face to face or online (National Back Exchange, 2010). The European Panel on Patient Handling Ergonomics (EPPHE) identified enduring complications and hurdles to introducing a manual-handling directive for patient handling (Hignett et al, 2014). This is a concern given that our knowledge of WRMSDs supports the principle of manual handling and safe practice as being more than just patient moving. It involves repetition and fixed positions along with bending and twisting. The barriers to implementing the directive were identified as being:
‘A lack of scientific evidence (including ergonomic standards) for specific patient handling techniques and equipment; a lack of standards for educational programmes including inter-agency interfaces for staff training.’
There is a responsibility for staff to reduce the risk as far as ‘reasonably practical’. However, education and knowledge about the risks of manual handling and this notion of ‘reduced risk’ continues to be a problem in many health and social care environments. The same minimisation or avoidance of the notion of risk may also apply to nurses and other health professionals working in the community setting. Much community work may involve transferring patients and equipment may be available for this. However, King et al (2018) highlighted the issues faced by staff in the home care setting, specifically the bathroom:
‘Small restrictive spaces, a poor fit between available equipment and the environment, a reliance on manual handling techniques (but insufficient space to use optimal body mechanics), attempts to maintain normalcy, and caring for unsteady and unpredictable clients.’
Although equipment and space may not be an issue, not all manoeuvres can be supported fully with mechanical assistance (King et al, 2018). These issues may not be fully addressed in eLearning moving-and-handling packages or within the time constraints of a face-to-face training day. Despite this, the employer could still have fulfilled their duty under MHOR (1992). They have trained staff to avoid and assess the risk, as well as providing equipment and allowing sufficient rest. Staff, by participating in the training, are informed about loads and their duty as employees to report a risk and request an assessment from the back care adviser/manual handling lead as required.
Although not all tasks can be supported with equipment and elements of bending, twisting and stretching are unavoidable, the back care adviser can advise on how to reduce the risk. Staff, however, may not contact the back care adviser for all tasks.
No risk assessment tool means no risk?
To accompany manual-handling training, there is now a growing number of manual-handling patient risk-assessment tools available for employers to introduce and employees to complete in the care environment. The HSE Health and Safety Laboratory (Pinder, 2002) explored some of these tools, comparing various features of each. These features included: injury focus, load/force, lift and distance, flexion and symmetry, frequency and factor interaction. Few tools actually addressed all of these issues and there were wide discrepancies 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 by Pinder (2002) from the Ovako Working posture Analysis System (OWAS) have a user-friendly appeal, requiring the individual to consider back, arms and leg position/posture as well as load for the activity. This is then categorised, and the user is directed to actions to be followed. It is important for staff to feel that a tool is easy to use and does not require input from an ergonomist for every activity. MHOR (1992) highlights TILEO as a risk tool, but this is not considered in the HSE review (Pinder, 2002). TILEO (Task, Individual, Load, Environment and Other) has been amended and sometimes referred to as TILEEO (Task, Individual, Load, Environment, Equipment and Other) (Table 4). This can be an easy tool to remember, however the ‘load’ focus can be seen as only pertinent to a lifting task and the task requires the individual to be aware of the risk involved, for example, in bending or twisting.
| TILEEO | ||
|---|---|---|
| T | Task | Does the Task involve: |
| I | Individual | Is training required? |
| L | Load | Is this a— |
| E | Environment | Space constraints? |
| E | Equipment | Is there equipment available to assist with the task? |
| O | Other | Is the client attached to equipment which may increase the risk? |
In the neonatal and infant care units of one trust, the lack of user-friendly risk-assessment tools, as detailed by clinical staff, and the lack of equipment suitable for the tasks, with staff also reporting that there were limited WRMSD risks in the wards, resulted in the creation of the Johnstone, Owen and Owen Risk Assessment (JOORA) for manual handling (Figure 2). Staff were consulted on the need for a manual-handling risk-assessment tool and the problems with existing assessment tools were discussed. The JOORA tool was developed and after various pilot studies, in a variety of care settings, the tool was rolled out Trust wide (Johnstone and Owen, 2017). Before the introduction of the JOORA tool, records showed that manual-handling risks and details about patient needs were handed over verbally at the bedside by nurses and completion of the previous manual-handling tool was sporadic (Johnstone and Owen, 2017). The introduction of the JOORA saw an 89% compliance rate and a 53% reduction in inappropriate referrals to the back-care adviser (Johnstone and Owen, 2017). Compliance was further improved by the introduction of an electronic version for staff working in critical care areas (Johnstone and Owen, 2017).
Figure 2 shows the JOORA tool for use by nurses working in neonatal units.
Conclusion
The problem of WRMSDs is not unique to the UK; for example, Ribeiro et al (2017) reported that 84% of Portuguese nurses reported signs and symptoms of having WRMSDs. Anderson and Oakman (2016) reported that WRMSDs remain problematic for all healthcare workers. It is clear that WRMSDs continue to be problematic for the multidisciplinary team in all care settings. Johnstone and Owen (2017) demonstrated how a manual-handling tool that is specific to the activities and environment of the role can have a positive impact on staff awareness of manual handling and associated risk. Individual workers must use tools that highlight risk and support the application of safe manual-handling principles to ensure that the risks in all tasks are reduced, alongside using equipment when available. It is through knowing the risks that individuals can consciously take actions to reduce them.