Handling training

This article examines new RCN training guidance – both a
book and a conference – on handling patients, by Greta Thornbory

Musculoskeletal injuries top the list of cases caused or made worse by work,
according to statistics from the Health and Safety Executive (HSE) 2001/2,
especially those which result in injuries involving handling, lifting and
carrying.1 This is particularly relevant to those whose manual handling
involves handling people. The past 12 months have seen a renewal of the
training guidance from the Royal College of Nursing (RCN 2003)2 and the
publication of the book Evidence-based patient handling (Hignet et al 2003).3
With quality healthcare under the auspices of clinical governance, practice
should be evidence-based and patient handling is no exception.

The RCN followed up its guidance and the publication of Evidence-Based
patient handling with a conference in London. Welcoming delegates to the
conference, Carol Bannister, OH adviser RCN, said the event was designed to
allow discussions around the book’s findings and to examine the potential of
the work in affecting patient handling practice. The book aimed to ‘bring
together all available research in a systematic literature review framework’
(Evidence-based patient handling, p3) and covered the background to research
and research criteria, as well as the results from the literature.

Three of the six contributing authors presented papers at the conference,
together with Howard Richmond from the RCN legal services, Sally Williams from
the HSE and Patricia Bartley, who introduced her work on a new approach to
patient handling training. The papers were followed by five concurrent
workshops based on the issues raised.

Dr Sue Hignett is a lecturer in ergonomics at the University of
Loughborough, and is leading a research project for the HSE to measure the
effectiveness of competency-based education and training programmes in changing
the manual handling behaviour of healthcare staff. At the conference, she gave
a rundown of the different research methodologies, critical appraisal and
discussed the nature of research evidence. By using the critical appraisal
approach, she has developed a systematic review of all the evidence to date on
patient handling for the book.

Consequently, her work provides a much-needed resource for all healthcare
professionals. One of the significant aspects of Dr Hignett’s paper was the
acceptance of research that was different from the medical model’s ‘randomised
control trials’ and it explored more suitable research designs (see box below).

This session was an excellent refresher for those who do not have daily
involvement, or who are new to, research.

The second speaker, Sue Ruszala, is a manual handling and ergonomics adviser
to United Bristol Healthcare NHS Trust. She spoke on the ‘controversial
issues’, reviewing the evidence and explaining why some techniques, once
accepted practice, were now regarded as hazardous. Cartoon pictures of
controversial lifts from the illustrator, Moira Munro, supported her talk.

Techniques were regarded as controversial if they were condemned,
inappropriate, and unsafe or presented a risk of injury – see box below. One of
the questions Ruszala asked was why, when there is research to support lifts as
hazardous, are they still used?

Emma Crumpton, consultant ergonomist for the RCN then presented her Back in
Work project, ‘Changing practice, improving health’. (Crumpton et al 2001).4
This work was funded by the Department of Health (England) and the HSE.
Previously, projects had focused mainly on the moving and handling of patients.
This project took place in three nursing homes in the Home Counties and was
based on the three core concepts or themes of:

– The prevention of injury

– Identifying causes of musculoskeletal health

– The promotion of good staff health and healthy backs

The initial objectives were to raise staff awareness through focus groups,
identifying problems and solutions by using a problem-solving approach and
updating resident’s care plans. Training played an important part, as did the
rationalisation of equipment provision.

OH was also regarded as one of the core aspects, and identifying suitable OH
provision was a priority. Outcomes were measured by a database, with
information from residents’ care plans, staff perceptions, a back questionnaire
and also a StaDyMeter, which is a form of ‘frequency log’ or self completing
diary. Results of these interventions showed care had improved, and exposure to
manual handling had decreased. Other factors it was concluded, were that
‘effective management is an absolute prerequisite for the change process to be
effective in reducing back symptoms in care staff’. This session concluded the
presentation from the authors of the book.

Patricia Bartley from movement specialists Corpus shared information from
the process of implementing outcome-based training. Bartley previously worked
in one of the largest NHS trusts in the UK and had first-hand experience of the
difficulties associated with generic based patient handling training – time and
money being key to the problems.

She outlined how they had identified problems that could be overcome by
people using the simple format of TILE (task; individual; load; environment)
and highlighting the need for individuals to carry out risk assessments for

Simple factors that had been overlooked by practitioners were things such as
encouraging patients to move for themselves and learning to use equipment, ie
adjusting the height of beds.

Personal injury litigation and human and disability rights are high on the
agenda for many practitioners who have to undertake manual handling tasks in
less than ideal environments.

Recent litigation has highlighted these factors and raised the issue of
whether one can refuse to lift patients who themselves refuse to be lifted
using a hoist.

Howard Richmond, deputy director of legal services at the RCN, discussed
several cases that had occurred over the past few years.

One factor raised in a particular case was that the local authorities had
not undertaken sufficient risk assessments and the courts ruled that it was not
the court’s place to do so, but that it was for the local authority as the
employer, to formulate manual handling policies.

Within the same case, mention was made of the dignity of the patient when using
a hoist, as it was felt that it could be regarded as ‘undignified’. Therefore,
the employers’ risk assessment for the employee was of great importance (HSE
2002) if the patient or client was refusing to be lifted using a hoist.5

Sally Williams, HSE inspector, was the last speaker of the day, and
explained how the criminal statutory framework influences patient handling
practice. Williams highlighted the six pieces of legislation which provide the
legal framework on patient/client handling in the UK:

– Management of Health & Safety at Work Regulations 1999

– Manual Handling Operations Regulations 1992

– National Health Service and Community Care Act 1990

– Charter of Fundamental Rights of the European Union

– European Convention for the protection of Human Rights and Fundamental

– Community Care (Direct Payments) Act 1996

She also identified the six factors necessary for the successful
implementation of a risk management system:

– Senior management commitment

– Worker involvement

– Risk assessment

– Control measures

– Instruction and training

– Proper management of cases

This was followed by some examples of prosecutions, and improvements notices
issued under the Manual Handling Operations Regulations over the last couple of
years – 32 per cent of which were due to deficiency in training and 28 per cent
to risk assessment.

To improve the situation, the HSE has made the following recommendations for
safer patient handling:

– Better data on risk is needed as evidence for nursing practice

– There needs to be greater focus on the patient’s needs and experience

– Training needs to be more focused, with emphasis on core skills such as
communication and body language

– Much more needs to be done from an ergonomics perspective.

A new word was introduced during the day: ‘haptonomics’. Haptonomy is
derived from the Greek words ‘hapsis’, meaning tactile contact, sense, feeling;
and ‘nomos’, meaning law, rule or norm. ‘Hapto’ means to establish a
relationship through tactile contact in order to heal, to make whole, to
confirm the other’s existence. It is a science based on the observation of and
experimentation with phenomena, which can be produced or verifiedÉ which
characterises in a very specific way the emotional experiences of humans.

Subsequent searches of this topic in nursing/medical literature and internet
search engines did not produce any more information, although the company
Patricia Bartley works for, Corpus, runs courses on the subject; see

It is the six success factors that form the basis of the new RCN manual
handling training guidance (RCN 2003)2 developed from a series of focus group
sessions held with stakeholders throughout the UK.

The main thrust of the guidance is the ‘Competencies for manual handling’
section, which is divided into domains:

– Domain 1: management of risk

– Domain 2: creating a safe system of work

– Domain 3: professional effectiveness and maintaining standards

Each domain is subdivided again into competencies to be achieved by three

– Back care advisers

– Line managers/appointed manual handling supervisors/key workers

– Patient/client handlers

The booklet goes on to say that these competencies can be used to identify
educational needs, underpin educational plans, curriculum and learning outcomes
for sessions and to assess competence.

The conference concluded with feedback from the five workshops, which
enabled participants to discuss a variety of issues surrounding topics such as
equipment, hygiene and other handling tasks in different settings.


Overall, the book, as a systematic review of patient handling research,
together with the RCN guidance and the conference, provided a good basis on
which to build and develop policies, and to update procedures and methods of
training for a safer system of patient handling than has previously existed. It
does not mean however that research should stop, and all speakers at the
conference agreed that more research into patient handling is needed.

If your job involves giving OH support and advice to those involved with
patient or client handling, the book and guidance are for you.

Greta Thornbory is a consultant in health and education


1. HSE, 2002, Causes and kinds of occupational/work-related accident and
injury, 2001/2, www.statistics.gov.uk

2. RCN, 2003, Safer staff, better care: RCN manual handling guidance and
competencies, publication code 001 975

3. Hignet S, Crumpton E, Ruszala S, Alexander P, Fray M, Fletcher B, 2003,
Evidence-based patient handling: Tasks, equipment and interventions, London,

4. RCN, 2001, Changing practice – improving care: an integrated back injury
prevention programme for nursing and care homes, publication code 001 255

5. HSE, 2002, Handling home care, HSG 225

Research designs


Fixed design     Flexible design


(quantitative)     (qualitative)


Experimental strategy    Case study


Non-experimental         Ethnographic


(quasi) strategy study    Grounded theory




BOXTEXT: Lifts classified as ‘unsafe’ RCN 1998


Shoulder slide   2 poles canvas lift


Leg and arm lift Flip turn on bed


Two-sling lift     Front assisted
transfer with 1 carer


Combine lift


Through arm lift            Walking
person linking arms


Cross arm lift    Draw sheet lift


3 or more person lift


Source: Hignett et al, 2003


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