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Elizabeth Hallows provides the latest best practice advice for the safe and appropriate manual handling of children

Do the words “manual handling” fill you with dread? Is it a boring subject, aimed at restricting children’s activities and used as an excuse to avoid inclusion? Does it bring up ideas of sitting in routine, inappropriate training sessions where the trainers focus on adults' handling needs? Well, I hope in this article to challenge these opinions and show that a sensible approach to manual handling can be enabling and positive for all those involved in helping children to move.

It is important to start by taking a look at what legislation and guidance does and doesn’t say about manual handling, and to whom it applies. 

Legislation

Health and Safety law requires employers, such as a local education authority (LEA) or school, to ensure their employees are kept reasonably safe whilst at work. The Manual Handling Operations Regulations (MHOR) are part of health and safety law and require employers to avoid, if possible, the need for their workers to carry out hazardous manual handling. If avoiding hazardous manual handling is not possible, the regulations require a risk assessment to be done and the risk to be reduced, as far as reasonably practicable. The appendix to the MHOR provides guidelines designed to act as a filter, to indicate when a risk assessment needs to be done. There are no safe limits for lifting weight in law.

Welfare and human rights law requires organisations to consider the rights, needs and wishes of individuals, both children and employees. Specifically, the Human Rights Act requires that people are not exposed to inhuman treatment (article 3) and that people must not be discriminated against (article 14). The United Nations Convention on the Rights of the Child states that children with disabilities should enjoy a full and decent life.

Guidance

The Guide to the Handling of People (5th edition) is widely regarded as the leading text on the subject and is used by expert witnesses in court as an indication of expected manual handling standards. The book has practical chapters with clear descriptions and pictures of evidence-based techniques, but very few of these apply to smaller children.

A paediatric handling special interest group has produced Guidance for Assisting Children and Young People to Move which has detailed descriptions of methods and equipment for helping children to move.

Scotland’s Commissioner for Children and Young People has written a report called Handle with Care, which looks at children’s experiences of manual handling and found that restrictive polices and rigid approaches limited children’s participation in activities and left many feeling like “cargo”.

The Health and Safety Executive has produced Health and Safety Matters for Special Educational Needs: Moving and Handling which states as guiding principles:

  • there should be a balance between the health and safety considerations of employees and individual students’ rights to dignity, autonomy and privacy
  • health and safety of employees should be sustained, but it is not an excuse for denying disabled students and students with SEN access to educational opportunities.


The following case study illustrates what all this means in practice.

Case study: John

John is a five-year-old who is starting mainstream primary school this September. He is a wheelchair user who is small for his age and weighs 19kg (3 stone). John is not able to stand but is able to self-propel his wheelchair and loves spending time on the floor where he can move around by shuffling. John’s parents lift him for all moves.

The school has never supported a child who uses a wheelchair before and the headteacher is worried about meeting John’s needs whilst also protecting staff who will help him move. In particular, the school is concerned that they may be acting illegally by lifting John on and off the floor and on and off the changing table for personal care.

Sarah, a qualified moving and handling advisor, considers factors required by the MHOR and carries out a manual handling assessment in consultation with John, his family, physiotherapist, occupational therapist (OT) and headteacher.

Assessment
Sarah starts by talking to John and his family about John’s capabilities to move and what help he and his family think he will need for specific tasks. John’s OT and physiotherapist talk about their recommendations for him, focusing again on which moves are required and on how John would most benefit from being moved.

Sarah looks at the school premises and notes the space available in the classroom, the toilet area and the corridors. She also asks about the experience and training of those who will be helping John to move.

It is clear from the assessment that John will benefit from being able to spend time on the floor with his classmates and that he will require help to move on and off the changing table fitted in the biggest toilet. Sarah’s job is to recommend a specific method of helping John move. Task by task, she considers all options in detail, as the following example task illustrates.

Task: transfer from wheelchair to floor

Option 1: John remains in his wheelchair at “carpet time”

Advantages:

  • avoids manual handling completely for this task.

Disadvantages:

  • John wants to sit on the floor with his classmates
  • John will spend more time in his wheelchair and not change position so often, so he may be less comfortable
  • increases emphasis on John being “different” to his classmates.     

Summary:

  • option 1 would reduce the manual handling risk to workers to a very low level, but at a high cost to John.

Option 2: mobile hoist and sling

Advantages:

  • avoids manual lifting for employees and so is likely to be safest possible option for them
  • will prepare John for likely future hoisting.

Disadvantages:

  • large, cumbersome equipment to use in a room of four- and five-year-olds
  • time consuming activity
  • employees not experienced in using a hoist are likely to find it awkward at first
  • costly to purchase and maintain
  • needs dedicated storage area
  • John is apprehensive about being hoisted.

Summary:

  • option 2 would reduce the manual handling risk to workers to a low level, but at a high cost to John, the school and his classmates.

Option 3: two people manually lift John using through arm lift

Advantages:  

  • quick technique
  • no equipment required (none of the disadvantages of hoisting).

Disadvantages:

  • Guide to the Handling of People (5th edition) states that this is a controversial technique, likely to cause harm to the person being lifted, by damaging their shoulders, as well as those lifting if the HSE weight guidelines are exceeded. The HSE weight guideline for a woman lifting to floor level is 7kg, so for two women this is 9kg (two thirds of the total).

Summary:

  • option 3 would result in a high risk for workers and John, but a low financial cost.

Option 4: two people manually lift John using a lifting sling onto a low surface and assist him to move onto the floor

Advantages:

  • quick technique
  • basic, low cost equipment required
  • easy technique for workers to learn
  • incorporates John’s goal of being able to move from a low surface onto the floor.

Disadvantages:

  • still involves manual lifting. It is necessary to decide whether the residual risk outweighs the benefits. Observing this technique being carried out by John’s parents, Sarah focuses on their posture and notices that the lifting sling enables less stooping and that by starting in a kneeling position, large vertical movements are not necessary and they can keep John close to their own bodies. She compares this to the HSE filter weight guidelines and considers that they are lifting within the 13kg box, so for two women this is 17kg.   

Summary:

  • option 4 would reduce the risk to workers and to John to a medium level at a low cost.

Recommendations
Sarah is aware that the MHOR require that risk is reduced “as far as reasonably practicable” and that this requires a balance between residual risk and the cost of reducing the risk further. She finds it helpful to draw up a chart (right) showing the relative residual risk and costs for each option.

Taking into account the recommendations of the HSE guidance and Scottish report (discussed above), Sarah recommends that, in this case, John be lifted by two workers using a manual lifting sling from his wheelchair onto a low surface, and then guided down to the floor. She advises on suppliers of the lifting sling and delivers tailored manual handling training for workers at the school, focussing on the use of the lifting sling with John. Sarah is aware that, as John grows, the balance of risk against cost will alter, and advises that his manual handling needs be reviewed every six months.

Conclusion

I hope in this article to have bridged the gap between the theory of manual handling risk assessment and the practical application of such information. Knowledge of legislation and guidance underpins the practical outcomes of manual handling risk assessments of children and ensures fair and thorough assessments.  

Further information

Elizabeth Hallows is a chartered physiotherapist with a particular interest in the moving and handling of adults and children with disabilities. She is a regular conference speaker on manual handling and works as a freelance manual handling trainer and advisor, and as an expert witness:
www.elizabethhallows.co.uk


The Guide to the Handling of People (5th edition) is edited by Jacqui Smith and published by The National Back Pain Association (2004). The organisation also provides information and support and promotes good practice under the name of Back Care: www.backcare.org.uk

The Health and Safety Executive's Health and Safety Matters for Special Educational Needs: Moving and Handling is available from:
www.hse.gov.uk/pubns/edis4.pdf

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