Guidelines for moving and handling people:

Do they improve practice?

David R. Thomas

Emeritus Professor, University of Auckland

dr.thomas@auckland.ac.nz

Yoke Leng Thomas ResearchWorks NZ

Moving and handling people: The NZ

Guidelines

1st version published in 2003 by ACC - 5 years to complete

2nd version published March 2012 by ACC 24 month review process Expert panel to guide development Survey of 50 users of 2003 Guidelines Draft version circulated for public comment Multiple submissions or comments on draft

Formation of M&H Association of NZ – 2011?

History of NZ Guidelines

UK – HOP6 (Handling of People v6, 2011) Australia

Qld Health: Think Smart Patient Handling Better Practice Guidelines 2010

Workcover NSW: Manual handling guide for nurses 2005 Worksafe Vic: Transferring people safely 2009

Canada OSHA, BC: Safe Patient & Resident Handling 2000 Worksafe BC: Handle With Care: Patient Handling and the

Application of Ergonomics (MSI) Requirements 2006

USA - CDC Safe lifting and movement of nursing home residents 2006

Examples of Guidelines: Other countries

ACC work-related entitlement claims for employees in health services around $8 million pa

ACC injury prevention initiatives to reduce injuries and their costs

Multiple workplace health and safety initiatives – ACC & Department of Labour

The DPI (discomfort pain and injury) framework used by ACC to address gradual onset injuries, especially in workplaces

Why ACC funds Guidelines

1. What evidence is available about the impacts of guidelines on practice?

2. What attributes of guidelines make them more or less effective for specific audiences?

3. What organisational processes or procedures facilitate or impede the use of guidelines in everyday practice?

Questions regarding guidelines effectiveness

General guidelines (broad and extensive) covering a broad area or set of topics in health and safety Moving and handling guidelines to prevent injuries

Targeted guidelines for specific health problems or events Preventing ladder injuries Guidelines for treating depression Guidelines for mild head injuries

Detailed protocols (brief & focused) for specific clinical practice Algorithms for specific movements when moving

and handling people

Types of guides and protocols

Three frameworks or perspectives relevant: Clinical trials framework favouring RCTs and experimental

trials, excluding non-experimental studies (systematic reviews) Evaluation framework using multiple types of evidence for

assessing effectiveness Descriptive accounts based on interviews with practitioners

No clinical trials or similar studies found for general guidelines

Some experimental trials/RCT studies for clinical protocols Several commentaries on clinical guidelines and protocols Developing literature on evidence-based clinical decision

rules and protocols (e.g., algorithms)

Review of literature: Impacts of guidelines

Example of Algorithm: Nelson et al 2003

Algorithms - Standardized processes for decisions about equipment & number of staff to perform high-risk activities safely (Nelson et al 2003)

Intervention included 6 program elements: (1) Ergonomic Assessment Protocol, (2) Patient Handling Assessment Criteria and Decision Algorithms, (3) Peer Leader role (Back Injury Resource Nurses), (4) State-of-the-art equipment, (5) After Action Reviews, (6) No Lift Policy

The program elements resulted in a statistically significant decrease in the rate of musculoskeletal injuries as well as the number of modified duty days taken per injury

Algorithms for patient handling and movement: Nelson et al 2003, 2006

Example of

guideline for head injuries

We did not locate any studies comparing multifaceted interventions that included PEMs with multifaceted interventions. Yet during our literature search, we retrieved 82 studies that compared the effects of PEMs with one or more interventions that included PEMs. … [There are] difficulties in separating the effects of PEMs when combined with other interventions. …. some studies used PEMs alongside other interventions for investigating additive effects of interventions …. Future intervention studies examining the effect of PEMs should consider the impact of educational materials on their own. (Farmer et al. ,2008, p. 14).

Example: Cochrane review of printed education materials (PEM) on clinical practice

Improve knowledge about topic Provide rationale for specific health and

safety practices (e.g. reduction of injuries)

Provide health and safety information for managers

Describe specific techniques and procedures for practitioners

Purposes of general guidelines

Survey of 50 users in 2010 - included M & H coordinators, trainers and physiotherapists

Most used sections were: techniques (72%), risk assessment (30%) and equipment (30%)

15/50 (30%) used external trainers Some of the changes recommended

Remove 16kg limit Simplify forms and audit tools Clarify who are audiences for each section More information about training

Survey of users of NZPHG 2003

Practitioners and trainers often hold strong views about best practice for M & H people

Most views are consistent Some conflicting views Revised version of the Guidelines

endeavoured to take into account both emerging consensus on best practice and conflicting views, for example… using brakes on mobile hoists exclusion of unsafe techniques

Context for M & H in NZ

1. Relative advantage: Is complying with the guideline superior to not complying with it in terms of its effectiveness and cost-effectiveness?

2. Compatibility: Is the guideline consistent with practitioners’ values, norms, and perceived needs?

3. Complexity: How easy is it to integrate the guideline into the current work practice?

4. Trialability: Can the practitioner test or try this guideline with relative ease?

5. Observability: Can the practitioner observe others that have incorporated the new guideline easily?

Factors affecting clinicians’ compliance with evidence-based guidelines (Gurses 2010)

Framework for assessing impacts of M & H guidelines - 1

CarersTraining, risk assessment,

techniques. use of equipment

Moving and Handling

Guidelines

Health and Safety StaffM & H Coordinators

Operate M & H programmesOrganise training

Audit M & H practices

Senior ManagementEstablish policy & programme

Provide resources

OutcomesReduced injuries,

absenteeism and staff turnover

Regulatory environment

(DoL, ACC)

1. Features of Guidelines docs and resources2. Health and safety regulatory environment in

NZ (e.g., legislation, compliance requirements, resource development, incentives)

3. Cultures in healthcare organizations (e.g., DHBs, private providers)

4. Characteristics of practitioners (e.g., health & safety awareness, professional associations, union support)

Framework for assessing impacts of M & H guidelines - 2

Multiple styles evident in existing guidelines and manuals (UK, Australia, Canada, USA)

Move to pictorial styles (photos) to accompany specific aspects (e.g., techniques, equipment)

Writing styles include; instructional/prescriptive, technical/ academic and descriptive.

NZ Guidelines (2012) reduced instructional text (compared to 2003) and used more descriptive and technical text. Includes more photos, tables, bullet points and examples (side boxes)

Features of guidelines: Presentation and writing styles

Target audiences identified Awareness of guidelines – professional associations,

government agencies, health & safety staff Access to guidelines

Print, online & DVD docs (pdf), video of techniques (DVD) Print friendly format for electronic pdfs

Readability – multiple styles, multimedia versions of key messages

Useability – can contents (techniques and procedures) be easily used by practitioners and managers?

Enhancing guidelines use and impacts

Extensive publication of guidelines for moving and handling people in developed countries

Few studies on effectiveness of guidelines – research on guideline effectiveness appears to be a low priority

Impacts of guidelines likely to be similar to other injury prevention/clinical practice initiatives

Readability and useability of guidelines likely to be important

Need for research on enhancing influence of guidelines on M & H practices

Conclusions 1 – Key points

Absence of evidence about effectiveness does not mean absence of effectiveness

Guidelines probably do improve practice: By providing information about specific

techniques and other resources By providing a set of standards for moving

and handling people Over time, through setting an agenda and

context for health and safety in moving and handling people

Conclusions 2 - Do Guidelines improve practice?

References

Farmer, A. P., Légaré, F., et al. (2008). Printed educational materials: effects on professional practice and health care outcomes. Cochrane Database of Systematic Reviews, Issue 3. Art. No.: CD004398 doi:10.1002/14651858.CD004398.pub2

Gurses, A. P., Marsteller, J. A., et al. (2010). Using an interdisciplinary approach to identify factors that affect clinicians’ compliance with evidence-based guidelines. Critical Care Medicine, 36(8 (suppl)), S282-S291. doi:10.1097/CCM.0b013e3181e69e02

Nelson, A. , Owen, B., et al. (2003). Safe patient handling and movement. American Journal of Nursing, 103(3), 32-43.

Nelson, A., Matz, M., et al. (2006). Development and evaluation of a multifaceted ergonomics program to prevent injuries associated with patient handling tasks. International Journal of Nursing Studies, 43(6), 717-733.