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Manual handling: a complex and multifactorial problem

Philippa Leggett
MSc Dip Biomech PGD (MH) MCSP SRP
Ergonomist and Manual Handling Consultant
Tyne Tees Health Consultancy

Back pain has contributed significantly to work days lost in the UK, accounting for more than €1.45 billion per year in care provision and the most common cause for long-term sickness absence in people in manual occupations.(1,2) Nurses and nursing assistants have the highest rates of musculoskeletal disorders among NHS staff in the UK.(3) Of these, back pain is the most common, and the most recurrent factor in the epidemiology appears to be moving and handling patients.(4) Addressing the way that nursing staff perform the manual handling of patients would therefore seem to be a primary factor in preventing work-related musculoskeletal disorders (WRMSDs). However, back pain is very difficult to categorise, and the risk factors for spinal pain are distinct from those for spinal problems and sickness behaviour.(5,6)

Risk assessment
EU member countries are subject to the Management of Health and Safety at Work Regulations (1992) and the Manual Handling Operations Regulations (1992, 1999), which dictate the requirements for accident prevention by imposing duties on employers and employees, which were originally laid down in the Health and Safety at Work Act (1974). While the precepts – avoid, assess and reduce – are applicable to both inanimate and animate load handling, problems arise in the field of person handling due to an inherent duty of care that all professionals undertake. The principles of assessment and action within these constraints mean that all manual handling duties must be the result of balanced decision-making that justifies the action within the context of the situation. In order to make a reasonable and balanced decision in the manual handling of people, including patient transfers, the risk assessment process involves four components:

  • The physical construction of the environment – for example, space, which could include obstacles, bed level, stairs, steps and doorways.
  • The human factors associated with the handler, including experience, knowledge, expectation, confidence, competence, physical capability and height.
  • The human factors associated with the person being handled – their height, weight, physical capability, mental capability, comprehension level, impairments and medical management, as well as other factors outlined above.
  • The job structure that people are working in – time, staffing levels, staff expectations, management style/support level, equipment provision, attitude to problem-solving, policies, protocols and procedures.

Safer handling
In the last five years, the simplistic introduction in healthcare of “no lifting” policies has been shown to be unrealistic and unachievable, and they are being replaced by “safer handling” policies. Since 1992, manual handling of loads and people within NHS trusts in the UK has been the remit of specialist manual handling and back care advisers, many of whom are appointed according to the recommendations issued by National Back Exchange, the association of manual handling advisers.(7)

Consider Figure 1. In some literature this manoeuvre is clearly outlined as “poor practice” as it places the handler in a poor biomechanical position and both the handler and the patient appear to be at risk.(8) However, the variation that individual patients display is the factor that dictates whether this manoeuvre could be used – obviously to use this on a frail elderly individual with poor skin integrity would be not just “poor practice” in manual handling but also challengeable in terms of duty of care.


In this instance (which cannot be indicated within the illustration), the patient was a teenager with cerebral palsy who required transferring onto a commode. She was able to bear weight, but only for a very limited time and it was uncomfortable for her. Usually she was transferred with a hoist; however, the battery was flat in the available hoist and it was therefore useless. This patient needed to be transferred to the commode as soon as possible, and as safely as possible for both individuals. The points to note here are that:

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  • The patient had to be able to assist with weight-bearing.
  • The patient had to be able to understand and appreciate the dilemma the handler was in.
  • The handler had to be experienced, knowledgeable and physically fit enough to perform this manoeuvre – preferably taller than the patient.
  • This manoeuvre was a “one-off” and the situation would alter back to using the hoist as soon as the immediate problem had been addressed. In other words, a replacement hoist would be found before a transfer to the commode is needed again.

Within this situation and with these provisions, this manoeuvre is both ethically acceptable and legally justifiable.

Ergonomics and evidence-based practice
Moving patients therefore requires an emphasis on assessment and problem-solving, rather than the prevailing technique-orientated approach sought by many practitioners. This in turn raises questions regarding training and individual competence as well as the structure of policy, protocols and procedures within a controlled environment such as a hospital or nursing/residential care.

In an attempt to standardise a manual handling strategy, interagency programmes have been introduced in some areas that appear to be working well within a limited geographical region.(9) However, they have yet to be analysed and evaluated to provide an evidence base, and evidence in manual handling is limited, according to Hignett et al, for use as the basis of effective practice.(10) Recent literature regarding guidance on the manual handling of people has made an attempt to begin the process, using both qualitative and quantitative evaluation tools – but the process is in its infancy.(8) A great deal of more robust research is required to add to the wealth of biomechanical evaluations in order to address the part played by the factors that lie within the assessment criteria outlined above. A full plan of ergonomic intervention and management is required in order to reduce the incidence of back pain. This would include:

  • Strategically implementing education relevant to employees’ work areas, remits and constraints.
  • Introducing relevant user-friendly equipment that staff know how to use and have no qualms about implementing.
  • Developing and introducing a fast-track management programme for staff experiencing back pain or problems, which includes education, exercise and counselling.
  • Investigating psychosocial factors at work such as stress, lack of management support, low staff morale, low staff numbers and lack of staff empowerment to make manual handling decisions.
  • Access for staff to exercise facilities at work with ongoing programmes aimed specifically at prevention as well as management.

The manual handling of patients is not a standalone subject that can be easily standardised. Manual handling forms part of patient care and overlaps other areas of care such as tissue viability. Touch is also an important part of human communication that should not be denied in care situations where pain and apprehension are likely to be present.(11) Patients’ independence should also be encouraged wherever possible as part of their rehabilitative process. Some generalised principles should be developed with robust research to underpin evidence-based practice, and the education of patients and families in safety behaviour, as well as nursing and care staff, should be addressed. This level of strategic implementation requires expert input from manual handling advisers with appropriate qualifications.



  1. Maniadakis A, Gray  A. The economic burden of back pain in the UK. Pain 2000;84:95-103.
  2. Chartered Institute of Personnel and Development. Employee absence 2004: a survey of management, policy and practice. London: CIPD; 2005.
  3. Leighton DJ, Reilly T.  Epidemiological aspects of back pain: the incidence and prevalence of back pain in nurses compared to the general population. Occup Med 1995;45:263-7.
  4. Smith DR, Mihashi M, Adachi Y, et al. A detailed analysis of musculoskeletal disorder risk factors among Japanese nurses. J Safety Res 2006;37:195-200.
  5. Croft PR,Papageorgiou AC,Thomas E, et al. Short term physical risk factors for new episodes of low back pain. Prospective evidence from the South Manchester back pain study. Spine 1999;24:1556-61.
  6. Burton AK, Tillotson KM, Main CJ, Hollis S. Psychosocial predictors of outcome in acute and subchronic low back trouble. Spine 1995;20:722-8.
  7. National Back Exchange. Essential Back Up. National Back Exchange: Towcester (UK); 2002.
  8. Smith J, editor. Guide to the Handling of Patients. 5th ed.  Teddington: BackCare; 2005.
  9. Derbyshire Inter-Agency Group. Care handling for people in hospital,community and educational settings. A code of practice. Derby: Southern Derbyshire NHS Trust; 2001.
  10. Hignett S, et al.  Evidence-based patient handling: tasks,equipment and interventions. London: Routledge; 2003.
  11. Argyle M. Bodily communication. 2nd ed. London: Routledge; 1988.

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