Equipment available in the PRAXIS Laboratory

Handling belt	Transfer boards	Turntable

Rope ladder	Patient handling blocks	A variety of hoists & slings (Trixie is only at Ealing)

Sliding sheets	Rollaboard	Crutches	Walking stick

Wheelchair	Beds	Zimmer frame	Lateral transfer sheets

Bridging facility

Videos

"Load Management Theory and Client handling techniques", Centaur Training.

"Phil E slide" instructional video.

NEW! "Sliding and gliding with Steve, Janet and John" - a guide to correct manual handling procedures covered in Module 2.

Books

"The Guide to the Handling of Patients Introducing a Safer Handling Policy" 4th Ed NBPA/RCN 1999

"Safer Handling of People in the Community" Back care 1999

MOVING AND HANDLING IN THE COMMUNITY

MOVING AND HANDLING – Guidelines for back care

BENEFITS OF NEW LEGISLATION FOR MOVING AND HANDLING

MOVING PATIENTS

MIND YOUR BACK

IMPROVING PATIENT MOVING AND HANDLING SKILLS

STUDY OF MOVING AND HANDLING PRACTICES ON TWO MEDICAL WARDS

HANDLING AIDS Handling  and moving patients

HANDLING AIDS   For nurses and carers

PREGNANT CLAUSES

MOVING PEOPLE

MANAGERS ATTITUDES TOWARDS MECHANICAL AIDS

A STUDY OF NURSES’ ATTITUDES TOWARDS MECHANICAL AIDS

AN ASSESSMENT OF MOVING AND HANDLING PRACTICES AMONG SCOTTISH NURSES

ASSESSMENT OF CLINICAL PRACTICE AND THE ROLE OF THE NURSE TEACHER

MOVING AND HANDLING IN THE COMMUNITY

Phil Cohen, Nursing Times February 4 1998

Christine Smith has developed a comprehensive education system that includes moving and handling patients, minimising risks to nurses and helping clients find the best equipment for their needs.

All three factors are closely related: if nurses are properly educated for work in the community they are less likely to injure themselves and if they know what aids are available, they are in a better position to help patients become more independent.

Up to now the moving and handling of patients in the home has been governed by guidance issued by the health services advisory committee to the Health and Safety Commission (Health Service Advisory Committee 1002). A revised version is due to be published soon and it will stress that there are particular problems in the community that require different agencies to work together and not duplicate their activities.

Age Concern (1997) Disabled Facilities, Grants and Older People Briefing Paper 2197. London: Age Concern England

Arthritis Care: (1997) Arthritis – Getting it Right: A Guide to Planners. London Arthritis Care

Health Services Advisory Committee: (1992) Guidance on a Handling of Loads

in the Health Services: London Health Safety Commission (revision due 1998).

RCN’S DEFINITION OF A SAFER HANDLING POLICY AS SET OUT IN APRIL 1996

The aim is to eliminate hazardous manual lifting in all but exceptional or life-threatening situations. Patients should be encouraged to assist in their own transfers, and handling aids must be used whenever they can reduce the risk of injury. Handling patients manually may continue only if it does not involve lifting most or all of a patient’s weight. Care must also be taken when supporting a patient, and pushing and pulling should be kept to a minimum. Staff should assess the capabilities of a patient to decide on which, if any, handling aids are suitable".

RCN Introducing a Safer Patient Handling Policy – London RCN 1996

RCN – RCN Code of Practice for Patient handling London RCN 1996

RCN: Manual Handling Assessments in Hospital and the Community – An RCN Guide : London RCN 1996

"Secombe I Patch – A Manual Handling and Lifting; A Review for the RCN; London RCN 1996.

Basic Handling Principles for Nurses

• Take a moment to assess the task at hand fully.
• Make sure that there is enough space to carry out the task.
• Check clothing worn by all participants to make sure there is full range of movement.
• Any attendant must he standing or crouching in a stable position.
• Check that hands are free and do not extend outside shoulder width.
• Ensure that your spine does not twist at any point – the load should be held close to the body.

Five point plan for the introduction of new lifting equipment

• Extra training for staff and the carefully staged introduction of equipment can prevent resistance from patients.
• Introduce a carefully planned lifting protocol for the assessment of each patient needs.
• Eliminate as many practical ergonomic problems as possible before introducing equipment.
• Train nurses fully in use of equipment
• Equipment itself should combine patient comfort with good ergonomic design
• Give a full explanation and introduction for patients, stressing the benefits both for them and nurses. Part of the explanation should be included on admission form.

References:

H. Knibbe – Overcoming Resistance, Nursing Times 1992; 82: 52: 46

Health & Safety Executive. Manual Handling Operations, Guidance on Regulations London

RCN and British Association of -- Bathing An Essential Service London RCN/BASW 1993

MOVING PATIENTS

Paul Lloyd, Community Nurse September 1997

The National Back Pain Association (NBA) and RCN guidelines for patient handling key points as follows:

• Nurses should never lift patients manually

• A patient-handling risk assessment should always be made prior to moving any patient.

• Appropriate equipment needed for moving or lifting a patient, once identified as necessary by the risk assessment should be obtained immediately.

• Management should plan in advance for all handling situations, including emergencies, and provide training equipment and support for nursing staff.

• Documented assessment of the load, the individual handling of the load and the task to be done.

• Measures to reduce the risk of injury should be identified and implemented and their effectiveness monitored – these may include:-

Training for staff and mechanical aids.

         In Community Nursing these might include:-

Changing the environment for example by removing furniture or a carpet.

Providing suitable equipment.

Considering the type of bed the patient uses and whether it needs to be changed.

Ensuring staffing levels, staff training and staff fitness are adequate.

• The shoulder lift used to be seen as safer than the orthodox lift or the through arm lift but in fact all these lifts are unsafe and the shoulder lift has led to more injuries.

• Other factors such as the height of the handler and the patient’s level of dependency affect the risks of patient handling

• Any manual lifting, except say for a small child, is now considered a proscribed

activity by the RCN and NBPA.

• Some nurses still believe that if they lift a patient on a handling sling all will be well. While it provides a firmer base for the lift, nurses are still lifting the patient’s weight and exposing themselves to a risk of injury.

• The RCN’s Code of Practice shows that lifting adults is unsafe under the HSE’s manual handling guidance.

References:

National Back Pain Association/Royal College of Nursing. The Guide to the Handling of Patients Middlesex: NBPPA/RCN 1997.

Health and Safety Executive. The Manual handling Operations Regulations: London HMSO 1993.

Gollancz D. Hazards of Nursing. Personal Injuries at Work; London Royal College of Nursing 1996.

Stubbs: D A Hudson, M.P., Rivers, P.M. et al. Patient handling and truncal stress in nursing. Processing of the Conference on Prevention of Back Pain in Nursing. Harrow: Northwick Park Hospitals 1980.

Royal College of Nursing, Code of Practice for Patient Handling. London RCN 1996.

MIND YOUR BACK

Anne Counsell, Journal of Community Nursing December 1994

Anne Counsell RGN, DN is a District Nurse for South Buckinghamshire NHS Trust was approached to implement and co-ordinate the programme to train district nurses. Her plan of action was:

• To train 15 core nurse trainers in moving and handling techniques.

• Each core trainer to be responsible for an area, ensuring that all nursing staff attend a half day theoretical and a half day practical session. Follow up assessments were to be carried out in the work place and all staff were to attend an annual update.

• The core trainers would form a support group to discuss problems, support each other and keep up to date with moving and handling articles, policies and issues that could be passed on to their team.

Findings from Training Programme

• Appropriate clothing for handling activities needed
• New set of guidelines written for community nurses.

IMPROVING PATIENT MOVING AND HANDLING SKILLS

Alison Scott, Community Nurse, November 1995, Volume 11 No. 2, 105

Back injuries caused by lifting patients are a common problem.  One study looking at the the training nursing staff in one unit had received and how this was applied in everyday practice revealed a failure to take environmental factors into consideration.

Key points:

• Training in manual handling should incorporate a problem solving approach

• The handling and moving of patients is a learned skill that needs regular revision.

• Assessment of patient capabilities is essential, as is the provision of a safe ergonomically satisfactory environment.

• There is no single technique that works in all situations.

Christine Green, British Journal of Nursing 1996, Vol 5, No. 5

This small exploratory pilot study was undertaken to explore the moving and handling practices of nurses working on two medical wards and to determine nurses’ perceptions of factors that might influence those practices. Data were collected by means of non-participant observation and semi-structured interviews. The results suggest that risk assessment of the task, load environment and individual capabilities, carried out in the clinical area, was often incomplete. Factors influencing moving and handling practice included insufficient equipment, lack of space, unsuitable uniforms, and negative attitudes towards changing practice. In view of changing practices, nurses need to be aware of the factors that promote or hinder moving and handling practice if they are to address these issues.

• The Health Service Executive (HSE 1992) provides an explicit framework for risk assessment in the workplace.

• Risk assessment of the task, load, environment and individual capabilities need to be carried out more thoroughly by both employers and employees.

• It is important for education and practice to consider the impact that attitudes may have on nurses’ moving and handling behaviour.

• In light of policy changes it is important for moving and handling education and practice to move towards a no-lifting or anti-lifting philosophy.

References:

Channon E (1992). The cost of caring. Nursing Times 88(41):27-9

Charney W Zimmerman K, Walara E (1991) The lifting Team AAOHN J39 (5) 231-4

COHSE (1992) Back Breaking Work. A Survey on Back Injuries Among Health Care Workers

Corlett E N Lloyd PV Tarling C Troup JDG Wright B (1992) A Guide to the Handling of Patients 3^rd edn. The National Back Pain Association in Collaboration with the Royal College of Nursing London

Counsell A (1994) Mind your Bank Community Nursing News

Field P A Morse JM (1985) Nursing Research The Application of Qualitative Approaches Chapman and Hall London

Gordon K (1991) Devising a Back Pain Prevention Package Nursing Standard 6(4) 25-8

Harvey J (1985) The Witney Healthy Back Survey Oxfordshire Health Unit, Oxford

Harvey J (1987) Back to the drawing board, Nursing Times 83(7): 44-8

Hersey P. Blanchard KH (1977) Management of Organisational Behaviour, Prentice Hall Inc. New Jersey

HSE (1992) The Manual Handing Operations Regulations: HMSO London

Institute of Manpower Studies (1992) Back Injured Nurses A Profile. A discussion Paper for the RCN London.

Johnson P (1992)Handle with Care. Nursing Times 88 (42) 28-39

Kane M Parahoo K (1994) Lifting: Why nurses follow bad practice. Nursing Standard 8(25): 34-8

Kimchi J Polivka B, Stevenson JS (1991) Triangulation: operational definitions Nursing Res. 40(6) 364-6.

Lewin K (1967) Field Theory in Social Science, Associate Book Publishers, New York

Lloyd P, (1990) Handling techniques for nurses. Nursing Standard 4(25): 24—5

McGuire T, Dewar B (1995) The assessment of moving and handling practices among Scottish Nurses Nursing Standard 9(40): 35-9

National Back Pain Association (1994) Back Facts; NBPA, Teddington, Middlesex

Orem D (1980) Nursing: Concepts of Practice, 2^nd edn. McGraw Hill, New York.

Ottaway R (1976) A change strategy to implement new norms, new styles and new environment in the work organisation. Person Review 5 (1): 13-8

Quinn F M (1988) The Principles and Practice of Nurses Education, Croom Helm, London

Stubbs D (1991) Ergonomics and back pain. Occup health 43 (3): 82-5

Stubbs D, Osborne C (1979) How to save your back, A comparison between the nursing profession and the construction industry. Nursing 1^st Series 3 (June) 116-24

Stubbs D, Buckle P., Hudson M, Butler P (1985) Nurses’ Uniform investigation of mobility. Int J. Nurs. Studies 22(3): 217-19.

Tarling C (1992) The right equipment. Nursing Times 88 (50) 38-40.

Venning P J (1988) Back injury prevention among nursing personnel: the role of education AAOHN J 36(8) 327-33.

Wright S G (1990) Changing Nursing Practice Edward Arnold London

Jane Seymour, Nursing Times 5 July Volume 91 No. 27 1995

The following are the main points to remember when handling a patient. However these points are a brief summary and are not attended as full guidance.

• Assess the task at hand
• If you can eliminate a potentially risky task or procedure, do so.
• If it cannot be eliminated ensure:-
• There is enough space to carry out the task.
• The attendant’s clothing does not restrict movement
• The attendant is standing or crouching in a stable position.
• Hands are free and do not extend outside shoulder width.

Some information in article on grab handles, monkey poles, posture beds and hoist and stair lifts.

Useful Addresses for more information on mechanical aids.

Disabled Living Foundation, 380 – 384 Harrow Road, London W9 2HU

Disability Information Trust,Mary Marlborough Centre,Nuffield Orthopaedic Centre,Headington,Oxford OX3 7LD

References:

European Council: Manual Handling of Loads, Directive 1990/269/EEC) Brussels: EC 1990

Health and Safety Executive: Manual Handling Guidance on Regulations: London HMS0 1992

Further reading:

Cochrane G M Wilson AK (Eds) Hoists and Lifts, Oxford Disability Information Trust, 1990

Disabled Living Foundation: Stairlift Checklist. London DLF 1990

Hall J Professional Development: Lifting and Handling Parts 1-3) Nursing Times 1995: 91 issues 1 – 3

Harpin P. Hoists. In Focus 1992 55: 14-15

Mandelstam M How to Get Equipment for Disability London Jessica Kingsley Publishers 1993

Thorpe S. Stairlifts and platform lifts. Access by Design 1992 59 19-21

Joanna Trevelyan, Nursing Times, February 21 Volume 92. No. 8 1996

The importance of using appropriate handing equipment when moving patients cannot be over-emphasised. With about one third of all work related injuries that are reported to the Health and Safety Executive caused by handling, lifting or carrying and some seven million visits made each year to GPs regarding back pain, the facts speak for themselves.

Information follows on self lift blocks, bed ladders, small transfer boards, turning discs, low friction rollers, supine sliding boards, handling slings, handling belts and Safety issues.

References:

Seymour J. Bathing Aids, Handling and Lifting in the home. Nursing Times 1995 91: 8 53-54

Seymour J. Handling aids, Lifting and moving patients. Nursing Times 1995 91 27 48-50

Willis J. Back care: preventing injury. Nursing Times 1995 91: 43, 44-46

Health and Safety Executive. Manual Handling Operations Regulations 1992 Guidance on Regulations London HMS0 1992.

RCN Advisory Panel on Back Pain in Nurses. Code of Practice for the Handling of Patients, London RCN 1992.

Ellen Goodwin, Gill Aston, Nursing Times October 26^th 1994

New moving and handling regulations during pregnancy will help women work in safety.

The new regulations will stress the need to assess hazards – chemical, physical and biological agents and industrial processes considered hazardous to the health and safety of the mother, foetus and during breastfeeding. Guidelines for such assessment will be provided by the European Commission:.

They should also take into account of movement and posture, physical fatigue and other work related physical stress. Key points in the directive include:

• Temporary change of occupation (within an organisation) to avoid risks, or extension of maternity leave where avoidance is not possible.
• Possibility for temporary transfer to day shifts (for regular nightworkers)
• Maternity leave of 14 weeks with pay equivalent to being off sick.

The first two items should increase the pregnant woman’s protection from the hazards of heavy work and postural stress, but it remains to be seen how employers will deal with problems identified through risk assessment.

Health and Safety Executive proposals for implementation of these changes in the law are under review following consultation which ended last June. (Final recommendations, which may include adjustments to the original proposals, have not been published at the time of writing).

RECOMMENDATIONS FOR MIDWIFERY PRACTICE

The following recommendations are made on the basis of the regulations and research quoted to enable midwives to review current practice and devise new strategies for client care as appropriate.

Assessment of clients at risk:

• Incidence of back problems before pregnancy
• Nature of occupation (not just job title); hours standing, lifting and so on.
• Health and safety support at work
• Size of family – other young children, dependent relatives, domestic responsibilities
• Is it a multiple pregnancy?
• Social circumstances/living conditions increased postural stress.

Availability of resources

• Back-care classes
• Specialist physiotherapy, assessment of specific problems, care and treatment

Midwifery education

• Health and safety regulations
• Moving and handling training
• Referral systems

Mantle M J Greenwood, R M Currey HLF. Backache in Pregnancy, Rheumatology and Rehabilitation 1977 16: 2 95-101.

Nwuga, VCB. Pregnancy and back pain among upper class Nigerian women. Australian Journal of Physiotherapy 1982; 8:4, 8 – 11

Health and Safety Executive. Draft management of Health and Safety at Work (Amendment) Regulations No. 199. Proposals to implement the health and safety provisions of the EC Directive on pregnant workers. London HMSO 1994.

EC Directives on minimal health and safety requirements for the manual handling of loads where there is a risk particularly of back injury to workers Official Journal of the European Communities 1990 33 L1156, 9-13,

HSE, Health and Safety at Work Act 1974. London HMS0 1974

HSE Manual Handling Operations Regulations. Guidance on Regulations; London HMSO 1992

Grieve GP. Common Vertebral Joint Problems Edinburgh. Churchill Livingtone 1981

Pheasant S. Ergonomics Work and Health; London Macmillan 1991.

Dyer C, Fidderman, H. Back pain at work. Occupational Health Review 1992: 39, 8-12

McHenry C. Handling legislation and employers response to back pain. Occupational Health Review 1993; 43 May/June 11-14, Polden M, Mantle J. Physiotherapy in Obstetrics and Gynaecology London, Butterwork-Heinemann 1990

Fast A, Shapiro D, Ducommun. E.J. et al. Low back pain in pregnancy. Spine 1987 12 – 4, 368-371.

Prentice C, McCue Canty, A. Jannowitz, I. The pregnant patient and her partner. Occupational Medicine 1992; 7: 1, 77-85.

Berg G, Hammar M, Moller-Nielsen J et al.  Low back pain during pregnancy. Obstetrics and Gynecology 1988; 71: 1, 71-75

Nicholls, J A, Grive, D W. Performance of physical tasks in pregnancy. Ergonomics 1992; 35: 3, 301-311.

Colie C.  Preterm labour and delivery in working women, Seminars in Perinatology 1993; 17:1, 37-44.

Cherry N, Physical demands of work and health complaints among women working late in pregnancy. Ergonomics 1987; 30: 4, 689-701

Marbury, M C. Relationship of ergonomic stressors to birthweight and gestational age. Scandinavian Journal of Work, Environment and Health 1992; 18: 2, 73-83.

Goulet L Theriault G. Association between spontaneous abortion and ergonomic factors. Scandinavian Journal of Work Environment and Health 1987. 13, 5, 399-403

Cruikshank D P , Hays P M.  Maternal physiology in pregnancy. In: Gabbe S.G. (ed) Obstetrics. Normal and problem Pregnancies Edinburgh: Churchill Livingtone 1991.

The Manual Handling Operations Regulations require all handling tasks to be assessed for risks to the carer.  The Disabled Living Foundation has produced a resource pack giving details of equipment designed to further these aims.

HANDLING EQUIPMENT

KNOW YOUR EQUIPMENT

• Did you know that there are more than 60 hoists and 150 slings on the market.

• Are you aware of the full range of small handling equipment.

• How do you know which is the most appropriate equipment for the staff and clients in your work area?

• Do you know about the pros and cons of the different features of the equipment?

• Where can you obtain the equipment?

• How much does it cost?

The Handling People Pack provides the answers to these questions and many others

The Handling Pack is based on the Manual Handling Operations Regulation 1992 and is obtainable from The Disabled Living Foundation, 380-384 Harrow Road, London W9 2HU. It costs $35.00

References:

HSE.  Manual Handling Operations Regulations. Guidance of the Regulations. Sudbury, Suffolk: HSE 1992

Mc Guire T, Moody J, Hanson M, Nursing Standard   Volume 11 Number 31/1997

This article reports a study of the attitudes of NHS Management and financial personnel to issues of moving and handling, in particular the use of mechanical aids. The study highlights some confusions about the responsibilities and roles of different personnel and the authors make some recommendations to clarify these.

The report highlighted that few respondents particularly finance directors know how much this problem was costing their own trust. This lack of awareness is highly likely to influence the financial provision made for purchasing handling equipment and the provision of insufficient funds was reported as the main obstacle in the purchase of mechanical aids.

Training had been the trusts’ main priority in complying with MHOR (HSE 1992) followed by obtaining other moving and handling equipment (such as sliding sheets) before the purchase of mechanical aids.

References:

Docker SM (1993). Effects of the European Community Directive on Lifting and Handling – Professional Nurse 8, 10, 644-649

Health and Safety at Work Act (1974) London HMSO

Health and Safety Executive (1992) Manual Handling Operations Regulations, London HMSO

A STUDY OF NURSES’ ATTITUDES TOWARDS MECHANICAL AIDS

Mc Guire T, Moody J, Hanson M, Tigar F, Nursing Standard on  Volume 11Number 4, 1996.

Publication of the Manual Handling Operations Regulations (HE 1992) focused attention on the use of mechanical aids for the purposes of moving and handling. However, nurses reluctance to use this equipment has been widely documented. The reasons for this are complex and the aim of this study was to examine in depth the effectiveness and acceptability of mechanical aids to nurses and clients. This article reports on the part of the study which surveyed nurses’ attitudes towards this equipment. The data were obtained by means of a semi structured interview schedule. One hundred and eighty five nurses from a selection of specialities were interviewed. Common problems identified by the researchers were lack of proper training in mechanical aid use. Recommendations are made which aim to address the issues raised. Phases 11 and 111 of the study will appear in the next two issues.

McGuire T, Dewar B, Nursing Standard Volume 9 Number 40, 1995

The aim of this study was to examine current practices within the Lothian Health Area in relation to reporting of occupationally induced musculoskeletal injuries, training in moving and handling, and use of mechanical aids. A sample of 5,184 nurses working throughout the health board was given a questionnaire containing both open and closed questions. The results showed a significant proportion of nurses had time off work due to musculoskkeletal injury and that this was related to grade and specialty. There was also a significant proportion of the respondents who did not report injuries and/or who experienced pain/discomfort, but did not take time off work.

Present moving and handling training appears to be inadequate and too infrequent for the needs of staff. These findings emphasise the need for a review of both accident reporting systems and training, in particular in the use of mechanical aids.

References:

Health and Safety Executive – Manual Handling Operations Regulation. – London HMSO 1992.

The European Community. The EC directive on manual handling. Official Journal of the European Communities. 1990. 33, L156, 9-13.

Health and Safety Executive. Health and Safety at Work Act London HMSO 1974

Health and Safety Executive. Management of Health and Safety at Work Regulations. London HMSO 1992.

Stubbs DA et al. Back pain in the nursing profession; epidemiology and methodology. Ergonomics 1983. 26, 8, 755-765

Gillman V. Backpain and charity. Nursing Standard 1992, 6, 30-51

Venning P L. Back injury prevention among nursing personnel. AAOHN Journal 1988, 36, 8, 327-332.

Health Services Advisory Committee. Guidance on Manual Handling of Loads in the Health Service, Sheffield, HSE Health and Safety Commission 1992.

Straker L M. Reducing work associated back problems in the health service. Physiotherapy 1989, 75, 12, 697-700.

Harber P et al. Nurses’ beliefs about causes and prevention of occupational back pain. Journal of Occupational medicine 1988, 30, 797-800.

Confederation of Health Service Employees. Back Breaking Work Banstead COHSE. 1992.

National Back Pain Association in collaboration with RCN. The handling of Patients a Guide for Nurses. Third edition. London BPA and RCN 1992.

Stubbs DA et al. Backing out in nurse wastage associated with back pain. International Journal of Nursing Studies.

Girling B et al. Prevention of musculoskeletal stress in hospital employees an ergonomic approach to training. In Megaw E (Ed) Contemporary Ergonomics, London, Taylor and Francis1988.

Collette Clifford, Nurse Education Today (1994) 14, 272 -279

The assessment of the practice of student nurses in the UK is a complex process that has evolved from school based practical assessment, carried out by nurse teachers to clinically based continuous practical assessment where students are assessed by clinical staff (i.e. registered nurses) on the ward. The role played by nurse teachers in the latter model is an advisory one in which they offer guidance to the clinical staff (i.e. registered nurses) on the ward. The role played by nurse teachers in the latter one is an advisory one in which they offer guidance to the clinical staff completing the assessment. Nurse teachers also monitor the process of assessment by monitoring and responding to learner evaluations of their clinical experience and by undertaking educational audit.

This system is not without problems and raises questions about the ideal "location" for assessment of clinical skills and the respective roles of registered nurse and the nurse teacher in the assessment process. It will be argued that the present system of distancing the nurse teacher from the assessment of practice creates a conflict in which perhaps the least experienced practitioners contribute the most to the assessment of clinical skills. A change in this system demands a review of the nurse teacher’s role with particular focus, first of all on time spent in clinical practice. This paper presents a preliminary analysis of this problematic issue. There are implications in this analysis for teachers and other groups of health care professionals.

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These pages have been prepared by Colin Baker, Safety Co-ordinator.