Managing Health at Work Partnership Information Network (PIN) Guideline

MANAGING HEALTH AT WORK

Guideline 4 Promoting safe manual handling

4.1 Introduction

Accidents and injuries cost an estimated 95 million a year in the NHS in the UK, including 12.5 million for back injuries and associated replacement staff (Nuffield Trust). Preventing back injuries can be cost-effective and programmes have shown, in some cases, an 84% reduction in hours lost from incidents involving manual handling.

4.2 Principles and values

It is acknowledged that working in the healthcare environment is unpredictable and unforeseen exposure to manual handling hazards will inevitably occur. However, through a programme of hazard identification, risk assessment, the implementation of control measures and constant monitoring, all reasonably practicable steps will be taken to minimise the risks to staff. The underlying principles for such an approach are found in the Health & Safety Commission (HSC) strategic document Securing Health Together (2000), which in summary aims to ensure that:

• work does not damage the health of workers or members of the public;

• people are not excluded from work because of ill health or disability; and

• individuals who have been ill are rehabilitated.

So, the main principle is to: 'Minimise the risk of injury to staff and patients from manual handling hazards in the working environment'.

The main injuries caused by manual-handling hazards are musculo-skeletal. Three types of measure can be adopted to reduce the risk of this type of injury occurring at the workplace, namely:

• good participative ergonomic practice;

• safe manual-handling practice; and

• appropriate rehabilitation following injury.

These measures are closely interlinked and need to be considered collectively rather than individually. They also need to be underpinned by effective senior management support and commitment.

4.2.1 Ergonomics

Ergonomics is the study of people and their working environment so that equipment or work systems can be designed to suit a person's ability and make them as efficient as possible. Using ergonomics to assess risk involves considering a range of factors, such as:

L	load
I	individual
T	task
E	environment.

plus work organisation (Manual Handling Operations Regulations 1992).

An ergonomic risk assessment will enable the identification of hazards and provide a means of risk reduction that will make working life easier, safer, and healthier for staff and patients alike. This may be carried out, for example, by providing equipment, changing the task or altering the environment. This process should involve those staff likely to undertake the task.

The main principle is to 'fit the task or activity to the person, not the person to the task'. For example, this may mean re-positioning a computer screen (raising the height) to prevent neck strain from too much neck bending.

4.2.2 Manual handling

A manual-handling activity is described as any activity that involves transporting or supporting a load (including lifting, putting down, pushing, pulling, carrying or moving) by hand or bodily force (from Manual Handling Operations Regulations 1992).

A manual-handling hazard is an activity or system of work that could cause harm. A risk reflects the likelihood that harm will occur, together with how severe that harm may be. In order to reduce the risks associated with manual handling, a specific risk assessment can be undertaken. Such risk assessment involves the identification of manual-handling hazards and the associated level of risk.

4.2.3 Rehabilitation of staff following a musculo-skeletal injury

The aim of the rehabilitation process is to return to employment any individual whose ability to work has been affected by injury. This involves an ergonomic assessment of their work with the aim of eliminating or reducing any tasks that present a risk and then establishing a phased return to full activities (Working Backs Scotland 2000).

4.3 The legal framework

The following regulations and guidance apply to the process of reducing manual-handling hazards.

• Health & Safety at Work Act (1974)

• Management of Health & Safety at Work Regulations (1999). Under these regulations all employers must:

  • assess and record all significant health and safety risks to staff;

  • re-assess those risks;

  • provide appropriate training; and

  • make sure all staff use equipment in accordance with training and instructions.

• Manual Handling Operations Regulations [MHOR] (1992). These regulations further define an employer's responsibilities towards manual-handling tasks. They say that each employer must:

  • avoid any dangerous manual-handling tasks so far as is reasonably practicable and possible;

  • assess any tasks that cannot be avoided; and

  • reduce the risk as a result of this assessment.

• Lifting Operations and Lifting Equipment Regulations [LOLER] (1998)

• Health and Safety Executive [HSE] Manual Handling in the Health Services (Revised 1998)

• Reporting of Injuries, Diseases and Dangerous Occurrence Regulations [RIDDOR] (1995)

• HSE (1992) Work Equipment - Guidance on Regulations, Provision and Use of Work Equipment Regulations 1992 (PUWER).

The Guidance on Manual Handling of Loads in the Health Services (1992) says that:

• all staff should be provided with appropriate training before carrying out any manual-handling tasks;

• all staff should have refresher training each year; and

• involving all staff, including medical staff, is vital.

4.4 The recommended approach to reducing musculo-skeletal injury

This section describes the seven key steps that need to be taken in order to reduce the risk of injury to staff resulting from manual-handling hazards in their working environment.

Step 1: Collecting information

Managers need to identify all potential manual-handling risks in the workplace.

Systems should be in place to allow access to, and the reporting and analysis of, relevant information. This information includes:

• wide-ranging information on sickness absence including causes;

• details of manual-handling incidents;

• existing risk assessments;

• relevant policy documents;

• information relating to any legal claims (potential and actual);

• the number of new staff joining the organisation;

• the number of available training places;

• staff turnover; and

• incident reports ( See step 7).

Step 2: Developing the manual-handling policy

The analysis of relevant information will allow the development of a Manual Handling policy, which will tackle the risks found in the organisation. The development of this policy should be a collaborative process involving health and safety advisors and committees, manual-handling advisors and co-ordinators, Occupational Health Service (OHS), and all managers and staff. Systems should be established to monitor and review the implementation of the policy and, most importantly, make sure that its requirements are met in full.

Step 3: Producing risk leave assessment reports

There is a legal obligation to carry out manual-handling risk assessments in areas and for activities that could cause an injury (MHOR 1992). These regulations also state that a risk assessment must be undertaken or reviewed annually if:

• there is reason to suspect that it is no longer valid; or

• there has been a significant change in the manual-handling operations.

  The risk assessment process should include 'participatory ergonomics', in other words, staff, experts (ergonomists, occupational health physiotherapist, manual-handling advisors, occupational health advisors) and managers working together to:

• assess risks;

• identify problem areas; and

• jointly develop recommendations (the control measures) and action plans to reduce the risks.

  All staff should undertake risk assessment on a needs basis. For example, a patient's level of dependence may alter over a period of days or even hours, and therefore their handling needs must be re-assessed accordingly.

Step 4: Prioritisation

From collecting information and carrying out risk assessments, an organisation should prioritise which control measures to put in place by first targeting areas and staff groups at highest risk.

Step 5: Putting control measures in place

Having completed the risk assessment process, it is vital to implement the control measures and action plans that have been developed in response.

The ultimate aim should always be to 'avoid or minimise the risk whenever possible'. For example, it is not necessary to lift or handle patients who can move themselves. If a risk cannot be eliminated or avoided, one or a combination of the following options should be considered. (This list is not exhaustive.)

• Change to another safer system of work

  For example, a patient cannot move very well in bed, and asks for help from staff to move up the bed. However, the patient can walk with help. It may be possible for staff to tell the patient to get out of the bed, step up towards the head of the bed, and then get back in. This encourages the patient to be independent and reduces the need for staff to be involved in a potentially dangerous task.

• Providing equipment

  Equipment must always be appropriate and suitable to the needs of the task (according to product evaluation) and specialist advice should be taken whenever necessary. Staff must also receive appropriate training and support. Organisations need to be aware of the law relating to maintaining equipment (for example, LOLER or PUWER).

• Managing caseload

  For example, an acute stroke unit will have varying patient dependency levels. A large percentage of the patients may be very dependent needing intensive rehabilitation by physiotherapy staff.

  The nature of therapy rehabilitation involves manual-handling techniques that might not be able to be replaced by equipment. In other words, "it is not always practicable to avoid manual handling in physiotherapy without abandoning the goal of the rehabilitation of patients" (CSP Guidelines on Manual Handling). To prevent injury to therapy staff, an increase in staffing or a reduction in the number of manual-handling activities may need to happen. This will involve collaboration all round and ongoing risk assessment.

• Structural changes

  Structural changes may need to take place, if the working environment has a risk of injury associated with it. Small spaces may be one of the identified hazards. For example, a patient needs help to go to the toilet but there is limited space within the toilet cubicle because:

• the door opens inwards into the cubicle;

• the toilet bowl is close to one wall, which would limit access of the assistant; or

• the basin in the cubicle limits space.

  The control measure would be to alter these factors, so as to make best use of the space available. Interim measures should be used until structural changes have occurred, for example, using another toilet area.

• Training

  The HSC 'Manual Handling in the Health Services' 2nd Edition (1998) recommends that:

• appropriate training should be provided before manual-handling tasks are carried out (maybe as part of induction);

• refresher training should be carried out, if training is to remain effective in the long term (the nature and delivery of the training will depend on the type of work being carried out); and

• records are kept of all training delivered to staff, including a description of the content of each course.

  We recommend that you record the percentage of staff receiving induction training before taking up their duties (attendance rates and did-not-attend (DNAs) rates should be recorded. This information could be used as a measure against identified performance indicators.

  The content of a course could include:

• legislation and local policy;

• ergonomics;

• risk assessment;

• back care;

• details of injuries;

• fitness;

• safe-handling principles;

• mechanical-handling equipment;

• using safe-handling principles when moving someone or something; and

• condemned manoeuvres.

  Training should help to encourage staff to assess the risk of each situation. Staff should then be able to use the safe-handling principles and best work practices that they have been shown. Staff must recognise that they have responsibility for the actions they take. Ongoing monitoring of safe practice should occur in the workplace via key-workers.

Step 6: Rehabilitation of staff following musculo-skeletal injury

If a staff member suffers a musculo-skeletal injury which affects their ability to perform their job, there is a need to provide a rehabilitation programme. To help this process a number of people need to be involved, such as ergonomists, manual-handling advisors, OHS staff, health and safety advisors, physiotherapists and HR staff.

Staff should be able to receive rehabilitation in a prompt and convenient way.

Outlined below is the process which should be carried out to support staff suffering musculo-skeletal injury.

• Assess and diagnose the injury and cause.

• Identify associated functional problems.

• Recommend a management programme.

• Put the management programme into practice.

  Elements of the management programme should include the following.

• Treating the injury

  There are a number of different methods, for example, physiotherapy, counselling, osteopathy, referral to a consultant specialist.

• Support from HR

  This can range from making sure that the staff member stays in contact with the organisation if they are on long-term sick leave or if their condition leads to ill-health retirement.

• Work-site assessment

  Providing an ergonomic assessment based on a staff member's capability and their worksite can reduce the risk of the injury happening again by making adjustments to the working environment or the activities and tasks which are carried out.

• A planned return to work

  Early return to work after injury or ill health can be achieved with the intervention of experts who understand the physical requirements of the job, human movement and the capability of the individual concerned. Facilitating a safe and timely return to work can be achieved through a multi-disciplinary approach, involving managers, the staff member, HR staff, the occupational health physiotherapist and OHS staff. (See also Appendix 4.C.)

  Every effort should be made to think creatively and flexibly to facilitate return to work. Factors that might be addressed include:

• hours of work and, within this, start and finish times;

• extra training;

• job sharing;

• restricted duties;

• mentoring;

• help with travelling; and

• working from home.

• Review and follow-up

  Follow-up is essential in order to make sure that recommendations and actions have been implemented and, if necessary, modified. For example, a weekly review meeting between the staff member, their line manager and the clinical case manager would assist the process of a planned return to work. In cases where the process of planned return to work takes place over many weeks, a monthly review meeting, including HR staff, would be useful.

Step 7 Reporting incidents involving manual handling

In order to identify the causes of manual-handling incidents, and whether or not trends are developing, all incidents must be reported, fully investigated and analysed. This will also help to:

• check whether everyone is following the letter of the law;

• check the effectiveness of prevention measures; and

• identify any problem areas.

  The depth of each investigation will vary depending on the nature of the incident. However, to be worthwhile any investigation must consider the underlying causes of the incident (HSC 1998).

  Certain incidents must be reported to the HSE under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR) 1995. Organisations must follow established incident-reporting protocols. This will also give an organisational record of all accidents and incidents that cause musculo-skeletal injury and ill health.

4.5 Evaluation

The following performance indicators can be used to ascertain whether or not the desired targets and outcomes have been achieved.

• Working hours lost as a result of manual-handling incidents.

• 20% reduction in the incidence of work-related ill health (Securing Health Together HSC 2000).

• The number of training places offered compared to the number of new staff.

• The percentage of staff receiving induction training before starting work (attendance rates and DNAs).

• The level of appropriate and up-to-date training provided.

• The percentage of staff receiving refresher training.

• The level of injury-related compensation.

• The level of injury-related early retirement costs.

• Litigation claims and costs.

• RIDDOR reports.

Systems and processes must be put in place to collect relevant data. However, having done this, it is possible that there will be a rise in the number of reported incidents in the short term. If this happens, it is because of the improvement in the reporting mechanisms, rather than an indication that the workplace is becoming less safe.

APPENDIX 4.A

The recommended approach to reducing musculo-skeletal injury