David R Thomas Emeritus Professor, University of Auckland Director, ResearchWorks NZ Ltd (P04,Thursday, Lower NZI Room, 8.30-9.15)

1. David R. Thomas
Emeritus Professor, University of Auckland
dr.thomas@auckland.ac.nz
&
Yoke Leng Thomas
ResearchWorks NZ

3.  ...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.

4.  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

5. 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

6. Risk assessment Techniques for
protocols M&H
Policy and Moving and
Training for
programme handling
all carers
planning people
Facilities and
Equipment
spaces for
provided
M&H

7. 1. Training is essential
2. Only training which includes hands-on practice is
effective (therefore much training is ineffective)
3. Training must be part of an overall program
4. Competencies learnt in training must be supported
in the workplace
What 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)

8.  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

9.  Slide sheets
 Mobile hoists
 Ceiling hoists
 Electric beds
 Wheelchairs

10. 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

12. 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.

13. 1. Training should address trainee needs and
communication styles
2. Active training – engagement (relevance to
workplace), practice & feedback
3. Management support - for training and
ensuring skills can be used in workplace
4. Monitoring and evaluation of training and
workplace practices (e.g. audits)

14.  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)

15.  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

16. 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 used
2. the population or sample used in the study
3. the type of intervention or group differences
reported
4. the outcomes from the study.

17. 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.

18. 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.

19. 11 studies included in review from 101 studies
closely evaluated - 6 RCTs, 5 cohort studies
The 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.

20.  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.

21.  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.

22.  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.

23.  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.

24.  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

25.  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

26. H – Index and control Interventions explicitly described?

27. (Column H – Intervention described= 9/16)

28.  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

29.  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

30.  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

31.  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

32.  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

33. 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)

34.  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

35.  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.

36.  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

37.  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)

38.  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.

39.  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