Several systematic reviews have concluded that manual handling training, including training for moving and handling people, has no effect on injuries among carers. In spite of these conclusions, many moving and handling programmes continue to include training as a core programme component. This paper examines the apparent contradiction between the research ‘evidence’ and everyday practice. A close examination of several of the systematic reviews indicates major flaws in interpretations made from the evidence base regarding the effectiveness manual handling training. The paper reviews the available evidence and outlines the types of training that are likely to be effective and ineffective. It concludes with reasons why training is an essential component of moving and handling programmes
Training in moving & handling: essential or superfluous?
David R. ThomasEmeritus Professor, University of Auckland firstname.lastname@example.org & Yoke Leng Thomas ResearchWorks NZ
...high quality systematic reviews have demonstrated the ineffectiveness of training for manual handling. ...recommends that the amount of training is substantially reduced and comments from international respected researchers regarding the ineffectiveness of training is included in the document. Training also needs to include methods such as self learning and web based learning.
Education – persuading people to alter their behaviour, for example through training Engineering – designing the work environment and providing equipment for moving and handling people Enforcement – requiring changes that reduce injuries by law or administrative rules, such as organisational policies and programmes
What are they? Programmes to reduce injuries among staff involved in moving & handling patients or clients A complex intervention combining multiple programme components that need to be planned and systematically implemented in workplaces
Risk assessment Techniques for protocols M&H Policy and Moving and Training forprogramme handling all carers planning people Facilities and Equipment spaces for provided M&H
1. Training is essential2. Only training which includes hands-on practice is effective (therefore much training is ineffective)3. Training must be part of an overall program4. Competencies learnt in training must be supported in the workplaceWhat is taught (and learnt) in training? Behavioural repertoires (placing a slide sheet) Skills (e.g. use of a mobile hoist) Competencies (risk assessment of clients) Knowledge (role of health and safety in preventing injuries, understanding a culture of safety)
Background and context – Descriptions of manual & client handling, relevant legislation, organisation policies Risk assessment - Risks to the carer, the client and the employer, costs of discomfort pain and injury Techniques – Overview including; sit to stand, lateral transfers, moving a fallen client, bed mobility, hoists and bariatric clients Equipment - Main types including slide sheets, transfer boards, hoists and slings Demonstration of selected techniques by trainers Practice of techniques by participants (trainees) Problem solving - Cases (scenarios) presented to trainees to select appropriate solution. Assessment of trainees
Slide sheets Mobile hoists Ceiling hoists Electric beds Wheelchairs
I was a nurse aide in this rest home. One day the manager wheeled in a hoist and told me to use it to lift the patient who was sitting on a commode and left me to it. So I hoisted a patient complete with commode and all. I didn‟t have any training on how to use the hoist. Moving and handling trainer
1. Apply the sling to client on floor (6 steps)2. Move the hoist into position – it is best to bring the hoist in from the client‟s head end. If this is not possible, come from the feet end.3. Lower the boom to its lowest position so it is easy to attach the sling.4. Attach the sling.5. The client‟s bed should be brought to the area.6. Hoist the client from the floor and position them on the bed.7. Remove the sling by tucking as much as possible of the sling underneath the client on one side and either sliding it out from the other side or rolling client away from it.
1. Training should address trainee needs and communication styles2. Active training – engagement (relevance to workplace), practice & feedback3. Management support - for training and ensuring skills can be used in workplace4. Monitoring and evaluation of training and workplace practices (e.g. audits)
Clinical trials framework favouring RCTs and experimental trials, using the hierarchy of evidence to exclude studies lacking design quality (systematic reviews) Evaluation framework using multiple types of evidence for assessing effectiveness and ensuring the intervention is adequately described – “opening up the black box” (Patton)
At least 8 systematic reviews of training (6 published in journals) Some RCTs on effectiveness of staff training (one program component only) No RCTs on programs with multiple components Extensive non-RCT literature on implementation, evaluation and cost effectiveness Moderate consensus on core outcome indicators (injuries, injury claims costs, staff absenteeeism) Widespread adoption of M & H programs in multiple countries & legislative enforcement in UK and about 8 US states
Synthesis of the main trends or findings in a carefully selected group of studies on a topic, using procedures intended to limit bias and random error (Cooper, 2009)Involves assessing the quality of a study‟s research methodology using criteria such as;1. the type of research design used2. the population or sample used in the study3. the type of intervention or group differences reported4. the outcomes from the study.
A traditional narrative review is a subjective exercise in which the author draws conclusions based on an idiosyncratic selection of the literature with no explicit methods of critical appraisal, analysis or summation of data. Not surprisingly, narrative reviews are susceptible to biased and misleading conclusions and are best regarded as viewpoints or opinion pieces rather than robust summaries of evidence.In contrast, a well-designed systematic review resembles a scientific investigation. … McCall, J., & Connor, J. (2010). Systematic reviews in public health research. Australian and New Zealand Journal of Public Health, 34(4), 343-344.
Level I: Evidence obtained from at least one properly designed randomized controlled trial.Level II-1: Evidence obtained from well-designed controlled trials without randomization.Level II-2: Evidence obtained from well-designed cohort or case-control analytic studies, preferably from more than one center or research group.Level II-3: Evidence obtained from multiple time series with or without the intervention. Dramatic results in uncontrolled trials might also be regarded as this type of evidence.Level III: Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.
11 studies included in review from 101 studies closely evaluated - 6 RCTs, 5 cohort studiesThe training interventions focused on lifting techniques, with duration varying from a single session to training once a week for two years. In three studies the training was supported by followup and feedback at the workplace. The lifting techniques were not described in detail. Three studies indicated the involvement of supervisors, and five studies encouraged participants to use available lifting aids. Most studies used a professional instructor.
In this systematic review we found no evidence that training with or without lifting equipment is effective in the prevention of back pain or consequent disability. Either the advocated techniques did not reduce the risk of back injury or training did not lead to adequate change in lifting and handling techniques Martimo, K., et al. (2008). Effect of training and lifting equipment for preventing back pain in lifting and handling: systematic review. British Medical Journal, 336(7641), 429-431.
We concluded that there is moderate quality evidence that [manual material handling] advice and training with or without assistive devices does not prevent back pain or back pain-related disability when compared to no intervention or alternative interventions Since it has been shown to be feasible to randomise both participants and groups of participants, there is no need for further cohort studies. More high quality randomised studies could further reduce the remaining uncertainty.
to determine whether there are interventions with proven efficacy that prevent back pain and back injury in nurses 51 papers were identified. 31 were deemed ineligible following review. Reasons for exclusion included lack of a control group, inadequate control, lack of between-group comparison, non-nursing subjects…. and failing to report back pain or injury symptoms 16 papers in final pool (8 RCTs and 8 NCTs. Studies with incomplete randomisation were classified as NCTs Dawson, A. et al. (2007). Interventions to prevent back pain and back injury in nurses: a systematic review. Occupational & Environ. Med., 64(10), 642- 650.
A lack of high quality studies and infrequent trial replication resulted in no strong evidence for or against any intervention method. Whilst no definitive statements can be made, moderate evidence from multiple trials suggests that multidimensional strategies are effective and manual handling training in isolation is ineffective. For all other interventions there is conflicting evidence or only single trials are available.
Many systematic reviews ignore verification of the training intervention ◦ Dawson 7/16 studies no description of training ◦ Martimo 4/11 studies had no description of training methods Not verifying interventions (for complex interventions) a major flaw in systematic reviews that invalidates their conclusions These are „black box‟ evaluations
Intervention outcomes or impacts assessed without an adequate description of what comprised the intervention (the active elements) No evidence that the intervention was delivered as described or planned (lack of verification) For complex & multisite interventions, no information about variability in delivery of the intervention across sites, delivery agents (e.g., trainers) or over time
H – Index and control Interventions explicitly described?
Best 1997- All staff (n =18) appointed to nursing jobs were given hospital orientation and a comprehensive 32 hour training course in Manutention. The training emphasized patient transfers and procedures relevant to the tasks in a geriatric nursing home. (p. 211) Rated 8/12 Horneij 2001- an individually designed training programme... In order to enhance adherence, the programme and how to fit it into everyday life, was thoroughly discussed with the participant. The exercises were thus individually adapted and individual goals were formulated. (p. 171) Rated 10/12
Primary emphasis on the study design Reductionism - selecting studies with only 1 or 2 components of M & H programmes to fit experimental & RCT designs Lack of description (verification) of the intervention (e.g., training) Evidence from non-RCT, non-cohort designs excluded from systematic reviews ◦ Credible evidence pre-post and qualitative studies ignored because it is seen as low quality
Simple interventions can readily be verified and/or target a specific condition or need that is responsive to the treatment ◦ increasing activity levels, reducing blood pressure, testing a new drug Complex interventions have multiple components, target multiple needs that may change only slowly over time, may vary across locations and have multiple outcome indicators ◦ e.g.,Moving & handling programs for healthcare staff
Number of and interactions between components within the experimental and control interventions Number and difficulty of behaviours required by those delivering or receiving the intervention Number of groups or organisational levels targeted by the intervention Number and variability of outcomes Degree of flexibility or tailoring of the intervention permitted
Many policies are informed or influenced by evidence that is discarded in systematic reviews RCTs & experimental studies often unrealistic for complex interventions that evolve and change over time RCTs & experimental studies usually not cost-effective as research strategies for organisations
Why has there been widespread adoption of M&H programmes in spite of lack of support from RCTs or experimental trials? Costs of staff injuries are high (for healthcare providers & insurers – ACC in NZ) Evidence is strong (persuasive) from non-RCT studies (e.g., pre-post studies) RCTs designs not feasible due to: ◦ Complexity of interventions – multiple components ◦ Incremental changes in programmes over time ◦ RCTs often not cost-effective for interventions in health care delivery systems ◦ Local program evaluations are more cost-effective (e.g. pre-post designs)
Economic evaluation at Canberra Hospital, Australia From 2000 to 2003, ACT Health had a dramatic increase in workers compensation premiums. Annual premium increases of 2m per year, By 2003, premiums had increased by $6m and totalled $11m in 2003/2004. Implemented O‟Shea manual handling program April 2005 – Mar 2006 Monitored workers compensation claims over period 2003-2007 (plus data for 2008) Cost of claims calculated
At end of 3-year period claims in clinical areas reduced by 60%, lost time by 79% Compared to pre-program claims costs, reduction in claims costs over 4 years (2005-2008) resulted in cumulative saving of $10.4 million Claims savings substantially higher than program costs Bird, P. (2009). Reducing manual handling workers compensation claims in a public health facility. Journal of Occupational Health and Safety: Australia and New Zealand, 25(6), 451-459.
18-month pre-post observational study Measured caregiver injuries 9 months before & after „Safe Patient Handling & Movement‟ project including techniques, algorithms & equipment 23 nursing home care & spinal cord injury units Estimated direct net benefit of intervention was $155,719 over 9 months post-intervention Annualized to 12 months $207,626, Net benefit of $2 million over 10-year period Payback period for the project was 4.3 years without including the indirect benefits
Training is an important component of injury prevention initiatives Systematic reviews can give misleading conclusions for complex programmes Training must be hands-on and involve demonstration, practice and feedback for tasks or skills being taught Skills taught in training must be supported by management and colleagues in workplaces (e.g., mentoring)
Bird, P. (2009). Reducing manual handling workers compensation claims in a public health facility. Journal of Occupational Health & Safety: Aust & NZ, 25(6), 451-459. Cooper, H. (2009). Research Synthesis and Meta-Analysis: A Guide for Literature Reviews (4th ed.). Sage. Craig, P., et al (2008). Developing and evaluating complex interventions: new guidance. London: Medical Research Council. Retrieved from www.mrc.ac.uk Dawson, A. et al. (2007). Interventions to prevent back pain and back injury in nurses: a systematic review. Occupational & Environ. Med., 64(10), 642-650. Martimo, K., et al. (2008). Effect of training & lifting equipment for preventing back pain in lifting & handling: systematic review. BMJ, 336(7641), 429-431.
Patton, M. Q. (2008). Utilization-Focused Evaluation (4th ed.) Sage. Siddharthan, K., et al. (2005) Cost effectiveness of a multifaceted program for safe patient handling. In K. Henriksen, et al (Eds.), Advances in Patient Safety (Vol. 3 pp. 347-358). www.ahrq.gov/qual/advances/ Verbeek, J., Martimo, et al (2012). Manual material handling advice and assistive devices for preventing and treating back pain in workers: a Cochrane Systematic Review. Occupational and Environmental Medicine, 69(1), 79-80. doi:10.1136/oemed-2011- 100214