David R Thomas Emeritus Professor, University of Auckland Director, ResearchWorks NZ Ltd (P03, Friday, NZI 6 Room, 2-2.30)

1. Guidelines for moving and
handling people:
Do they improve practice?
David R. Thomas Yoke Leng Thomas
Emeritus ResearchWorks NZ
Professor, University of
Auckland
dr.thomas@auckland.ac.nz

2. Moving and
handling
people:
The NZ
Guidelines

3. History of 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?

4. Examples of Guidelines: Other
countries
 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

5. Why ACC funds Guidelines
 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

6. Questions regarding guidelines
effectiveness
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?

7. Types of guides and protocols
 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

8. Review of literature: Impacts of
guidelines
 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

9. Example of Algorithm: Nelson et al
2003

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

11. Example
of
guideline
for head
injuries

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

13. Purposes of general guidelines
 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

14. Survey of users of NZPHG 2003
 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

15. Context for M & H in NZ
 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

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

17. Framework for assessing impacts
of M & H guidelines - 1
Regulatory Senior Management
environment Establish policy & programme
(DoL, ACC) Provide resources
Moving and Health and Safety Staff
Handling M & H Coordinators
Guidelines Operate M & H programmes
Organise training
Audit M & H practices
Outcomes
Reduced injuries, Carers
absenteeism and staff Training, risk assessment,
turnover techniques. use of equipment

18. Framework for assessing impacts
of M & H guidelines - 2
1. Features of Guidelines docs and resources
2. 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)

19. Features of guidelines:
Presentation and writing styles
 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)

20. Enhancing guidelines use and
impacts
 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

21. Conclusions 1 – Key points
 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

22. Conclusions 2 - Do Guidelines
improve practice?
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

23. 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.