Manual patient handling in the healthcare setting : a scoping review

Background Manual patient handling is the most frequently reported risk factor for work related musculoskeletal disorders in healthcare. Patient handling tasks are routinely performed manually without assistive devices and can create awkward postures and high loads for nurses and allied health professionals (AHPs). However, AHPs, notably Jo ur na l P re -p ro of physiotherapists, also utilize therapeutic handling to facilitate patient movement during rehabilitation. Objectives To comprehensively map the literature surrounding manual patient handling (without assistive devices) by healthcare practitioners. Methods AMED, CINAHL, MEDLINE, SPORTDiscus, and EMBASE databases were searched. Grey literature was sourced from Google Scholar, EThOS, Open Grey, Health and Safety Executive, National Institute for Occupational Safety and Health and Work Safe Australia. Literature published in English between 2002 and 2021 was included. Results Forty-nine records were included: 36 primary research studies, 1 systematic review and 12 ‘other’ including narrative and government reports. Primary research was predominantly observational cross-sectional (n=21). The most common settings included laboratories (n=13) and hospitals (n=13). Seven research questions were identified, with patient handling practices (n=13) the most common. Nurses formed the largest practitioner population (n=13) and patients were often simulated (n=12). Common outcomes included tasks performed (n=13) and physical demands during patient handling (n=13). Conclusion and implications of key findings This comprehensive scoping review identified that most research was observational, investigating nurses in hospitals or laboratories. More research on manual patient handling by AHPs and investigation of the biomechanics involved in therapeutic handling is needed. Further qualitative research would allow for greater understanding of manual patient handling practices within healthcare.

serious workplace injuries (1 week or more off work) as A$14 million within healthcare settings [9]. Investigation of the prevalence of WRMSD within HCPs internationally has reported rates ranging from 28-96% in nursing and allied health populations [9,10]. Oneyear prevalence of WRMSDs within physiotherapists has been reported as 58-67%, with therapeutic handling identified as an associated risk factor [11,12]. However, there is a lack of evidence investigating the risk of injury related to a flexed lifting posture [13].
Legislation on manual patient handling and associated training varies across geographical locations. Staff involved in patient handling within the NHS are required to complete annual online theory and in-person training sessions to learn recommended moving and handling principles to reduce their risk of injury [3]. Within the US, safe patient handling and mobility (SPHM) programs have been implemented in 11 states. These programs aim to improve safety of HCPs by encouraging the use of assistive devices during patient handling [14]. The majority of states, however, have not implemented SPHM programs [14].
Lifting aids and equipment can be used to improve safety of manual patient handling through decreasing the loading experienced by HCPs [14]. There are situations, however, that require nurses and AHPs to manually facilitate patient movement [1]. For example, assistive devices often require use of a sling where placement and removal can be a physically demanding task, involving moving and rolling of the patient. These patient movement tasks are completed manually by HCPs as there are no mechanical devices to aid with these steps [2]. In addition, AHPs, notably physiotherapists use therapeutic handling to aid a patient's rehabilitation. Therapeutic handling is when therapists use their own body in "guiding, facilitating, manipulating or providing resistance" to the patient [3]. The therapist J o u r n a l P r e -p r o o f will manually move and handle the patient to achieve therapeutic benefit [3].
Given the growing body of literature investigating manual patient handling undertaken without the use of assistive devices, this scoping review aimed to map that literature and identify gaps for future research. Further research could benefit HCPs by providing a more comprehensive understanding of manual patient handling. Patient handling techniques could then be improved to reduce risk of injury to HCPs. Manual patient handling in this scoping review was defined as any patient handling task that was completed without the use of an assistive aid including assisting with transfers, moving patients for care tasks or dressing, and placing of slings or sheets under patients. This scoping review forms the first step in a programme of research on manual patient handling.
A preliminary search of MEDLINE, CINAHL, JBI Evidence Synthesis, Open Science Framework, Cochrane library and PROSPERO did not identify any published or in-progress scoping or systematic reviews on the topic.

Review questions
The objective of this scoping review was to map what information sources were available relating to manual patient handling in healthcare without assistive devices. Two broad review questions related to the primary research identified by the scoping review were: 1) What is the current evidence-base on moving and handling of patients by healthcare practitioners? and 2) What primary research has been conducted on moving and handling of patients by healthcare practitioners? In particular we wanted to answer the following

Methods
This scoping review was conducted in accordance with JBI guidance for scoping reviews [15] and followed an a priori registered open access protocol [16]. The full inclusion and exclusion criteria for the scoping review are outlined in Table 1. Qualified and unqualified staff were included as in some geographical locations (e.g., UK) both staff groups are required to undertake manual handling training and perform patient handling.
Literature from any setting was included where it involved HCPs manually assisting patients (real or simulated by healthy volunteers) for tasks or transfers, including in laboratory settings. Guidelines for moving and handling differ across geographical locations. We included literature from any of the 62 very highly developed nations as defined by the Human development Index (HDI) [17] to ensure the findings would be relevant to the UK context.

Search Strategy
The search strategy aimed to locate published and unpublished primary literature, systematic reviews, text and opinion articles and educational resources. An initial limited search of AMED (EBSCOhost), CINAHL (EBSCOhost) and MEDLINE (PubMed) was undertaken using the keywords (TX moving and handling OR TX manual handling) AND (MH nurse OR TX nurs* OR TX physiotherap* OR TX allied health*). The text words contained in the titles and abstracts of relevant articles, and the index terms used to describe the articles were used to develop a full search strategy. The search strategy, including all identified keywords and J o u r n a l P r e -p r o o f index terms, was adapted for each included information source and a second comprehensive search was undertaken on 12 th August 2020, and updated on 10 th November

Source of Evidence Selection
Following the searches, all identified records were collated and uploaded into Covidence (v2477; Veritas Health Innovation, Melbourne, Australia) and duplicates removed. Titles and abstracts were initially screened independently by three reviewers (KJ, KC, AP) against the inclusion criteria for the scoping review. Good agreement was found after 10% title and abstract screening. As this scoping review formed part of a doctoral research programme, after good agreement was established, one researcher (KJ) conducted the remainder of title and abstract screening. Three reviewers (KJ, KC, AP) were initially involved in full-text screening, however after good agreement was found following 30% of the screening, one reviewer (KJ) completed full-text screening. Regular review and discussion with the review team was maintained throughout evidence selection. Full-text records that did not meet the inclusion criteria were excluded, and reasons for exclusion are provided in supplementary material.
J o u r n a l P r e -p r o o f <Table 1 around here>

Data Extraction
Following JBI methodological guidance, a charting table was created to record key information from the included records. The information extracted is presented in the supplementary materials. Data were initially extracted independently from 10% of the included articles by two reviewers (KJ, KC), extractions were consistent, therefore, one reviewer (KJ) completed the remaining data extraction with regular team consultation.
Authors of articles were contacted to request missing or additional data where required; at the time of writing no authors have responded.
Different study types of the included records were charted. The study types included observational cross-sectional, observational cohort, pilot, and qualitative. Observational cross-sectional research included data collected at one point in time, with observational cohort data collected over a period of time. Pilot studies were defined as such by study authors and included feasibility studies and a number of studies where the type was not clearly defined (pilot-undefined).

Data Analysis and Presentation
Search results and included records are summarized in a PRISMA flow diagram [19] ( Figure 1). Summaries of data from all included literature are displayed in Table 2

Study Inclusion
Initial screening of databases retrieved 8,638 records, with an additional 31 records identified from grey sources. Following removal of duplicates, 6,956 records remained for title and abstract screening. Of these, 430 records proceeded to full text screening. Fortynine records met the inclusion criteria and are included in the review ( Figure 1).

Characteristics of included studies
A summary of general characteristics of all included records are reported in Table 3. The 'other' literature included narrative text (n=8) [56][57][58][59][60][61]66,67] and educational pieces (n=4) [62][63][64][65]. Narrative texts described legislation, directives and previous research and were largely published in the US (n = 7). Additionally, narrative texts and opinion pieces provided education materials and guidance for improving manual patient handling in settings ranging from the community to operating theatres.

<Table 3 around here>
The following sections of the scoping review are focused on the primary research identified (n=36) in order to address the review sub-questions.

Questions addressed by primary research
Aims and objectives of the included primary research were reviewed and multiple research questions were identified, with some comprising sub-questions. The research

Populations
The summary of populations included in the review is displayed in Table 4. The largest staff population included in the review was nursing, with many studies investigating both qualified and unqualified staff (n=9) [21,25,33,34,41,42,44,49,52]. There was  Outcome measures were separated into measurement domains and tools, with the measurement tools grouped according to the domain they were used to measure, and are displayed proportionately in Figure 2. Physical demands and tasks performed were the most frequently investigated domains. Kinematics showed the most variation in measurement tool. Two primary research studies investigated staff training and its effect on incidence of reported WRMSD [21,42]. One study quantified the risk of WRMSD with associated with nursing tasks by using ergonomic assessment tools [22]. A table of all included outcomes and references are included in the supplementary materials. Within primary research published in the last 5 years there has been an increase in use of qualitative measurement methods, especially to investigate practitioner perceptions and experiences.

Discussion
In this scoping review, the literature on manual patient handling in healthcare was identified and examined, providing a comprehensive map. This allowed for a focus on manual patient handling tasks that require manual assistance from HCPs or involve therapeutic handling. The literature comprised a range of records with a variety of outcome measurement tools. Primary research studies incorporated a variety of outcome tools to address their specific research question.

Research
This scoping review included 49 records, of which only one was a systematic review J o u r n a l P r e -p r o o f published in 2010. This suggests a need for further robust evidence synthesis, which can inform practice within healthcare. As will be highlighted further in the discussion, potential systematic reviews for which there may be adequate evidence include HCPs movement during manual patient handling tasks. The most common study design was observational cross-sectional. These studies are generally time efficient and inexpensive to perform and allow for investigation of multiple outcomes [68]. Observational studies, however, are generally unable to establish cause and effect and may identify a range of spurious factors that would lead to ineffective interventions if developed [68]. Further well-designed research including therapeutic handling, handler movement and handler perceptions is required to better establish the factors that increase risk of injury and to provide appropriate targets for interventions.
The evidence base investigating AHPs is small in comparison to nurses. Nursing forms the largest occupational group within healthcare globally [69] and a high rate of WRMSDs has been found within the profession [70]. However, AHPs perform many of the same tasks, in addition to therapeutic handling to aid patients' rehabilitation. Therapeutic handling can be manually intensive with little research exploring how these tasks are performed, how manually intensive they are, and the potential risks associated with performing them regularly. Within the five included records that investigated physiotherapists, three investigated patient transfers with only one investigating therapeutic handling.
This scoping review found that it is more common to explore which tasks are performed during manual patient handling than to investigate how they are performed and their burden through exploration of biomechanics including the joint angles and internal J o u r n a l P r e -p r o o f forces experienced. Research conducted more recently investigated personal factors, experiences and perceptions of patient handling with a variety of observational and qualitative methods. Many studies used healthy volunteers as simulated patients, especially in laboratory-based research. Volunteers enable laboratory investigations to occur where more detailed measurements can be made, but may lack ecological validity where they do not accurately represent patients with physical or cognitive deficits. There is a lack of research conducted within outpatient and community settings, where healthcare practitioners need to adapt their practice to each patient's environment and the equipment they have available [61], and this needs to be addressed. Research conducted outside a laboratory environment can provide a more realistic and comprehensive account of the movements involved. However, there is less control over variables with a risk of losing some of the precision laboratory settings can provide. A limitation of research in clinical settings, especially for kinematic analysis, is the lack of access to gold-standard measurement tools such as Vicon or OPTOTRAK [71]. Instead, research frequently used 2-D video, photographs and inclinometers. On balance, the findings from this scoping review identify there is a need for both research with the tools and control of the laboratory as well as the naturalistic setting of hospitals and the community.

Narrative literature
The remaining literature sources included within this scoping review mostly comprised narrative summaries of legislation and government statistics. The legislation surrounding moving and handling in the UK was last updated in 2002. NHS staff involved in moving and handling are required to complete training following principles of safe manual handling, however, the evidence behind the training is unclear [72]. In addition, there is no J o u r n a l P r e -p r o o f specific AHP training for correct moving and handling of patients in a therapeutic manner.
Literature originating from the US has a focus on SPHM programs with an emphasis placed on using assistive devices to aid manual patient handling. Programs based on assistance devices are not found universally across the US, however, with HCPs still required to manually move and handle patients for certain tasks or movements.

Gaps in the literature
Few studies have focused on AHPs performing manual patient handling despite these staff groups being likely to be involved with therapeutic handling practices which are manually intensive. There are no current guidelines or formal training provided to AHPs within the UK for correct therapeutic handling, and this review found no evidence that such training occurs in other geographical locations. This is therefore a priority area for future research. Despite manual handling being identified as a significant factor involved in development of WRMSD, a lack of research was identified within this scoping review.
The records identified in this scoping review demonstrate that there is a lack of detailed measurement of manual patient handling in healthcare settings with real patients, with many articles measuring trunk position or using video or photos for full body analysis.
Measuring patient handling in laboratory settings is more accurate via access to 3D motion analysis systems. However, these often involve simulated patients and thus may not accurately reflect how healthcare practitioners move and handle real patients in the healthcare environment. Technology used to collect data in healthcare settings does not allow for the recording accuracy of laboratory-based systems, however, due to recent advances in technology this is an area that could now be explored further.

J o u r n a l P r e -p r o o f
Few studies qualitatively assessed moving and handling of patients in healthcare.
Ethnographic research and further investigation into perceptions and experiences of patient handling could allow for improvement of staff training and guidance to reduce risk of injury.
Of the records included in this scoping review, one primary research study was conducted within the UK. More research is required internationally, and especially in the UK, to inform this local context and to allow relevant evidence to help guide and improve staff training content or methods of teaching to reduce the risk of injury on HCPs.

Strengths and limitations
This scoping review followed a comprehensive search strategy and protocol that was reviewed by an experienced research team with previous experience in scoping reviews.
There remains the possibility that some relevant articles were not included which is also likely to be the case as the search was restricted to the English language. The methodological quality of literature included in this scoping review was not assessed in keeping with methodological guidance for scoping reviews where the aim was to map the available literature rather than to assess its quality or the implication of study findings. Most of the included research was conducted in the US and Canada, therefore there may be difficulty with generalizing findings to other healthcare contexts.

Funding
This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.

Ethical approval
Ethical approval was not required for this study.

Conflicts of interest
The authors declare no conflict of interest.