As with mobility, handling situations are experienced in all aspects of life. Adults automatically lift babies and children, and processes of fetching, carrying, moving and rearranging are part of maintaining a functional environment. Back pain is associated with mechanical loading of the spine yet this chapter presents evidence of numerous factors affecting human performance. The nature of nursing work logically suggests that nurses are particularly at risk of back injury. The adult human form is an awkward load to move; it weighs several times more than a heavy bag of shopping, has no handles, lacks rigidity, may be uncooperative, and is liable to severe damage if mishandled or dropped. Add to this the confinements of clinical and community settings and the requirement to move people between beds, trolleys and toileting facilities, and nurses are faced with a situation that would be tolerated by few industrial workers. Injuries and accidents attributed to moving and handling constitute an enormous and costly problem in the health service (Department of Health 2004).

The overwhelming focus of literature relating to manual handling is staff health and safety, yet poor practice inevitably threatens the safety and potential recovery of patients. Legislation, supported by guidance from professional organizations, continues to be introduced, updated and amended to provide a framework for moving and handling practice. You will learn that this may pose conflicting demands in your day-to-day work. New methods rapidly evolve as knowledge in this field develops and innovative equipment continues to be manufactured. Moving and handling therefore represents a dynamic and rapidly developing area of health care that has implications for the safety and well-being of all involved.

The purpose of this chapter is to unravel some of the complexities surrounding moving and mobility and provide direction to your practice. It is important to recognize that practising patient handling in a skills laboratory or reading about recommended techniques is not enough to equip you with the skills required in clinical practice. This chapter does not describe specific manoeuvres but emphasizes principles of patient handling, incorporating an ergonomic approach, to promote safer practice.

Joint range, muscle power, coordination and proprioception (awareness of the spatial position and movement of the body) are all vital to independent mobility. Exercise is fundamental in maintaining functional mobility because it improves or maintains these factors and contributes to general fitness, function, coordination, balance, relaxation, circulation and stability. Exercise also has psychological benefits with evidence suggesting improved self-concept and reduced anger, depression, anxiety and stress. Exercise is therefore necessary to maintain or improve our health. The level of an individual’s physical fitness is determined mainly by their capacity for energy output, neuromuscular function, joint mobility, and psychological factors (e.g. motivation) (Bouchard et al 2007).

Reasons for impaired mobility are diverse. Physically, mobility is restricted when specific structures involved in facilitating movement (bones, joints, muscles and the nervous system) are affected by disease or injury. However, illnesses or degenerative conditions (such as cardiorespiratory disorders, Parkinson’s disease or Huntington’s chorea) and psychological and social problems can indirectly reduce functional mobility. Equally, impaired mobility, whether temporary or permanent, affects other systems of the body. This has important implications for nurses since many potential complications can be prevented or minimized by nursing interventions (Box 6.2).

The spinal column comprises 33 bones (vertebrae) with discs between them. Its functions include distributing forces, providing attachments for ligaments, muscles and ribs, and as a protective cover for the spinal cord. For descriptive purposes it is divided into five sections (Fig. 6.3) but mechanically it functions as a single unit. Each vertebra is composed of a main body of bone at the front (vertebral body), the vertebral foramen (the vertebral arch) which surrounds the spinal cord, bony projections (spinous processes) situated at the back and at the sides (transverse processes). These provide the attachment for muscles and ligaments (Palastanga et al 2004).

The human spine, of which the spinal column and cord are component parts, forms a shallow ‘S’ shape when viewed from the side. These curves are a vital part of the way the spine functions and give it strength and stability. The vertebrae are different shapes and sizes according to their type and function. For instance, the cervical vertebrae are smaller and their shape is designed to facilitate movement of the head and neck, whereas the lumbar vertebrae have larger bodies to carry more weight. Disc structure follows a similar pattern. The whole structure is designed to resist compressive forces and to facilitate a variety of movements (Fig. 6.4; Palastanga et al 2004). The spine is flexible but is strongest when maintained in its normal alignment (‘S’ shape). Persistent poor posture, such as forward bending, twisting and slumped seated positions, and excessive, repetitive or awkward manual handling tasks increase the risk of back disorders; however, a strong back that has adapted to mechanical loading is less likely to become injured (Adams & Dolan 2005).

The relationship between back problems, poor posture and load handling techniques is explored along with the importance of an ergonomically friendly environment for moving and handling.

Precise data on the extent of back injury in our society are difficult to achieve since the pathology and associated risks are complex and diverse. For example, pain may be caused by disc herniation, muscle strain or bone degeneration; individuals may be at risk because of genetic and lifestyle factors as well as the nature of their work. However, evidence suggests that back pain is experienced by the majority of adults although most individuals cope without seeking treatment (May 2005). Episodes of back pain are often short-lived but they may be a precursor to more serious or prolonged disorders.

Certain predisposing factors help identify those who are at greatest risk of developing mechanical damage to spinal tissues (Adams & Dolan 2005) and these are listed in Box 6.3.

Risk factors refer to characteristics that make a person susceptible to a particular condition (May 2005). Although these are presented in a workplace context, they are equally relevant to other daily activities. In terms of low back pain, risk factors can be grouped into two major areas: biomechanical and psychosocial.

Since the publication of the Manual Handling Operations Regulations 1992, increasing emphasis has been given to ergonomic approaches to moving and handling (Nicholls, 1997 and National Back Exchange, 2002). The word ‘ergonomics’ is Greek in origin and means natural laws (‘nomo’) of work (‘ergo’). The guiding principle of this science is to optimize the match between the demands of a task, whether physical, social or psychological, and the capabilities of the individual performing it. This can be achieved by designing appliances, adapting the environment, introducing or reorganizing systems of work or changing the task.

Examples of ergonomic approaches to assisting people with mobility include:

Ergonomics, therefore, aims to ‘fit’ the work situation to the people to improve performance, safety, health and well-being (Bridger 2002).

In developed countries, full mobility is often viewed as the norm and impairment of this function as abnormal and undesirable. In other words, it is seen as a disability. This can create social, psychological and physical barriers in a society that is structured around ‘able-bodied’ people. Disability is a multifaceted concept (LoBianco & Sheppard-Jones 2007) and it is important to examine this to appreciate how it might impact on everyday lives.

There are two major models of disability, the medical model and the social model. The first identifies a disabled person as someone with a physically limiting condition or impairment. For example, the Disability Discrimination Act (DDA) 2006 defines a disabled person as someone having a physical or mental impairment that has a substantial and long-term adverse effect on his or her ability to carry out normal day-to-day activities. (Further information on laws relating to disability can be found in the Professional Knowledge section.) The World Health Organization (WHO; 2008) defines impairment as any loss or abnormality of psychological, physiological or anatomical structure or function. These definitions would include, for example, people with learning difficulties, non-standard forms of communication, hearing or visual impairment or those requiring mobility aids. The impairment, therefore, is the physical or psychological deviation from ‘normal’ and the disability is what results from that change. A limitation of the medical model is that impairment and disability are not always directly related. It is possible to have a high degree of impairment (biomedical change) with a low degree of disability (loss of function) and vice versa. Consider an example where two individuals suffer from a prolapsed intervertebral disc. Scans may reveal the same degree of ‘impairment’, that is identical degrees of anatomical damage, but the disability or extent of function could vary greatly.

The social model of disability focuses on society’s response to disability rather than the individual. It proposes that disability only exists because society refuses to remove environmental barriers that people with impairments encounter. As such it offers a very different meaning of disability. Public perceptions of disability do not distinguish between these concepts and the terms ‘impairment’ and ‘disability’ are used interchangeably. Goffman (1963) considers that the greatest problem faced by people with a disability is not their functional limitations but society’s response to them (see Ch. 19 for further discussion).

From birth to adulthood, mobility related goals are perceived as part of normal development, not only by health professionals but also by the community. We need only to look at our own environment, where there are steps, narrow doorways and cramped workplaces, to see the boundaries created for a person with impaired mobility. Arguably, schools have been designed with the expectation that children are fully mobile and therefore ‘disabled’ children were expected to attend a special school. In the past, and to an extent today, institutions were designed to house those with disabilities for most of their lives which served to marginalize them from the rest of society. The introduction of the Special Education Needs and Disability Act 2001 makes it illegal for educational establishments, in particular in further and higher education, to discriminate against students with a disability. In general, progress has been made to ensure provision of access and facilities in schools and other public places. Recently, attempts have been made to integrate children with special needs into mainstream schools. This remains a controversial topic of debate since, although the notion of normality is promoted through socialization, it is argued that resources are insufficient to meet the children’s particular needs.

Caring for people in hospital and community environments involves not just nurses but healthcare professionals from a range of disciplines. The terms ‘interprofessional working’, ‘integrated care’, ‘interagency working’ and ‘collaboration’ are all terms currently used to describe integrated approaches to health care (Atwal & Caldwell 2002). Integrated care pathways (ICPs) are structured, multidisciplinary care plans which outline essential steps in the care of a patient with a specific clinical problem (Campbell et al 1998). A single document may therefore be used to facilitate the management of patients or clients with mobility problems where several disciplines are involved. Where appropriate, individual care plans may be written by occupational therapists, physiotherapists or nurses. This is usually determined by whichever profession makes first contact. The ‘single assessment process’ is a key target in the National Service Framework for Older People (Department of Health 2001) that involves one person-centred assessment to which different disciplines contribute. This aims to facilitate integrated provision of services and effective management of care. Nurses play an important part in this coordinated approach because of their close, regular contact with patients.

Using tools and scales has become increasingly important in helping nurses to manage individual care more effectively. They assist in producing a more objective assessment of an aspect of care or provide a numerical measure of risk. In addition, they provide evidence that these processes have been undertaken. For example pain may impede a person’s mobility which may in turn place them at risk of developing pressure ulcers. In these instances tools such as pain scales and risk assessment tools for pressure ulcers would be useful in the overall management of this type of patient (see Ch. 11, ‘Pain’, and Ch. 15, ‘Skin integrity’, for full descriptions). Various tools exist to assess mobility. One example is the Barthel Activities of Daily Living (ADL) scale (Mahoney & Barthel 1965) which measures dependency on a 0 to 20 point scale. Another is the Assessment of Motor and Process Skills (AMPS) which is considered to be more sensitive in community settings (http://www.ampsintl.com/).

To provide a holistic approach to mobility assessment it is important to remember that factors such as the person’s beliefs, motivation and their perceptions of mobilizing need to be taken into consideration. Similarly, when assessing children or individuals with learning disabilities or mental illness their levels of understanding need to be taken into account. When preparing for discharge it is useful to undertake assessment in the patient’s own home or in very similar conditions. For more information please access Evolve 6.2.