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TROPHI: Development of a tool to measure complex, multi-factorial patient

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ISSN: 0014-0139 (Print) 1366-5847 (Online) Journal homepage: http://www.tandfonline.com/loi/terg20

TROPHI: development of a tool to measure

complex, multi-factorial patient handling
interventions

Mike Fray & Sue Hignett

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complex, multi-factorial patient handling interventions, Ergonomics, 56:8, 1280-1294, DOI:
10.1080/00140139.2013.807360

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Ergonomics, 2013
Vol. 56, No. 8, 1280–1294, http://dx.doi.org/10.1080/00140139.2013.807360

TROPHI: development of a tool to measure complex, multi-factorial patient handling

interventions
Mike Fray* and Sue Hignett
Loughborough Design School, Loughborough University, Loughborough, Leicestershire, UK
(Received 20 November 2012; final version received 13 May 2013)

Patient handling interventions are complex and multi-factorial. It has been difficult to make comparisons across different
strategies due to the lack of a comprehensive outcome measurement method. The Tool for Risk Outstanding in Patient
Handling Interventions (TROPHI) was developed to address this gap by measuring outcomes and comparing performance
across interventions. Focus groups were held with expert patient handling practitioners (n ¼ 36) in four European countries
(Finland, Italy, Portugal and the UK) to identify preferred outcomes to be measured for interventions. A systematic literature
review identified 598 outcome measures; these were critically appraised and the most appropriate measurement tool was
selected for each outcome. TROPHI was evaluated in the four EU countries (eight sites) and by an expert panel (n ¼ 16)
from the European Panel of Patient Handling Ergonomics for usability and practical application. This final stage added
external validity to the research by exploring transferability potential and presenting the data and analysis to allow
respondent (participant) validation.
Practitioner Summary: Patient handling interventions are complex and multi-factorial and it has been difficult to make
comparisons due to the lack of a comprehensive outcome measurement method. The Tool for Risk Outstanding in Patient
Handling Interventions (TROPHI) was developed to address this gap by measuring outcomes to compare performance
across interventions.
Keywords: patient handling; MSD; outcome measures; risk management

1. Introduction
Since 1992, the management of manual handling risks to workers in the European Union (EU) has been directed by the
Manual Handling Directive (Council Directive 1990). However, EU directives are general guidance and each country
develops their own response in time and detail (Hignett et al. 2007). A range of ergonomics and other approaches have been
used to reduce the risks, e.g. assessment and management, training, equipment provision, culture change (Hignett 2003), but
comparing the effectiveness of interventions has been difficult due to the use of different outcome measures (Menzel 2004).
The presence of musculoskeletal disorders (MSD) and illness in the health and social care workforce has been reported
in many epidemiological studies (Baldasseroni et al. 2000; Battevi et al. 2000; Estryn-Bahar et al. 1990; Fanello et al. 2002;
Hignett 1996; Hildebrandt 1995; Ore 2003; Smedley et al. 1995; Smith and Secombe 1996) with reports of high prevalence
rates among nursing and related personnel, which has continued in the twenty-first century. The Nurse Exit Study (NEXT)
study (seven countries) found that high levels of musculoskeletal and psychosocial risk factors are still prevalent in
healthcare workers (Simon et al. 2008). There was a correlation between physical lifting and bending and the prevalence of
back and neck pain, with psychosocial factors showing a stronger link with disability from MSD (Menzel et al. 2004; Viera
and Kumar 2009). Staff in hospitals reported the lowest availability of lifting equipment compared with nursing homes and
home care.

1.1 Aim
The aim of this study was to develop a single assessment tool which could be used by Patient Handling Practitioners (PHP)
to measure outcomes and compare performances between intervention strategies (single and multi-factorial) across a range
of healthcare organisations in four European countries. The objectives in the development of the Tool for Risks Outstanding
in Patient Handling Interventions (TROPHI) were to:
(1) Accurately measure effects of any intervention strategy for patient handling risks, in any given situation.
(2) Incorporate measures for all aspects of patient handling performance.
(3) Be usable by practitioners to evaluate progress in their organisations (internal assessment).

*Corresponding author. Email: M.J.Fray@lboro.ac.uk

q 2013 Taylor & Francis

 Ergonomics 1281

(4) Allow comparison across different locations (intra-agency and inter-agency).

(5) Be robust for data collection and analysis to allow for multi-centre research programmes (EU comparison).

2. Methods
A participatory and iterative process was used for developing the requirements, design, development and evaluation of
TROPHI (Figure 1). The study design used a systematic literature review in parallel with a focus group study. The literature
review identified the range of interventions, outcomes and outcome measurement tools. The focus groups (PHPs) discussed
and ranked the preferred outcomes.

4 EU Focus Groups (n = 36)

Critical appraisal of relevant
2 Expert international Focus Groups
literature (n = 328 papers)
(n = 10)

Preferred outcomes (n = 210) Range of outcomes (n = 598)

Grouped into 20 themes and voted as Staff, Patient
as 12 highest ranked themes Organisation, Task

FG themes and outcomes

from literature combined

Identification of outcome
measurement tools

TROPHI (V1)

UK site visits (n = 2)

TROPHI (V2)

UK expert review (n = 9)

TROPHI (V3)

Review, test and evaluation

(i) Translation and facilitator review (EU)
(ii) EU trials (n = 8 sites, 2 per country)
(iii) EPPHE review panel (n = 16)

Figure 1. Study design.

2.1 Systematic literature review

Literatures were collected using the same search strategy as Hignett et al. (2003) and extended to December 2008 (with the
addition of the Proquest access portal). Papers were screened for quality and content, and scored by two reviewers using a
validated critical appraisal checklist (Downs and Black 1998). Papers were included if they described a workplace
application of a patient handling intervention, pre-/post-comparisons, treatment versus control comparisons or multiple
treatment comparisons, and excluded if the research related to epidemiology of MSD was not the primary source or was a
legal case report.
Data were extracted about the design of the study and characteristics of the interventions, outcomes and beneficiaries.
The outcomes and beneficiaries were categorised as patient (physical, clinical or subjective outcomes for the patient being
moved), staff (e.g. reducing risks and improving comfort), organisation (including cost of accidents or injuries, and legal
actions against the service provider) and task for outcomes relating to functional benefits, e.g. time taken or a quality
measure of the task. Each paper was scored with a quality rating (QR; Downs and Black 1998), Level of outcome measure
(Robson et al. 2007) and Practitioner rating (Hignett et al. 2003).
The systematic review also identified the range of methods used to measure each of the preferred outcomes. The
following critical inclusion/exclusion criteria were used to select the most suitable method for inclusion in TROPHI
[version 1 (V1)]:
1282 M. Fray and S. Hignett

. High-quality research with paper QR rating . 50%.

. Evidence of peer-reviewed validation studies.
. Previously used to score a peer-reviewed intervention trial.
. Most frequently used measurement devices in patient handling studies.
. Complexity of the data collection in healthcare.

2.1.1 Systematic literature review findings

A total of 777 additional papers were retrieved with 121 meeting the inclusion criteria. These were added to 207 from the
previous review (Hignett et al. 2003), resulting in 328 included papers. The beneficiaries, outcomes (n ¼ 598; Table 1) and
intervention strategies (Table 2) were recorded for each study. Staff outcomes were the most frequent (n ¼ 429), followed
by organisation (n ¼ 83), patient (n ¼ 44) and task (n ¼ 32).
Both the range of interventions and possible outcomes informed the researchers of the range of information for possible
discussion in the focus groups. The outcomes included in the literature review were used to assist the development of the
definitions of the preferred outcomes from the focus groups.
Patient handling research has tended to evaluate interventions using MSDs in healthcare staff as the outcome measure.
Four systematic reviews (Amick et al. 2006; Bos et al. 2006; Dawson et al. 2007; Martimo et al. 2008) reported very little
high-quality evidence and a limited quantity of moderate evidence to show reductions in the rate of MSDs, especially from
multi-factorial interventions (Amick et al. 2006). As the focus for these reviews was MSDs and with known difficulties in
proving the effects of workplace interventions (Straker et al. 2004), it is important to consider the range of outcome
measures that might be used to evaluate interventions.
The focus on MSDs as the key outcome measure limits the number of studies available for consideration. An inclusive
approach for systematic review (Pluye et al. 2009) allowed a wider range of studies (e.g. qualitative evaluations, case
studies and comparison studies) to be included in a systematic review (Hignett 2003; Hignett et al. 2003). This included
many different and multi-factorial interventions with a wide range of outcomes and measurement methods to quantify
different aspects of performance, risk and outcome.
The analysis of outstanding (residual) risks has been considered using (a) individual patient handling risk assessments
and plans, (b) physical environment risk assessments, (c) individual observational tools for specific handling tasks (posture,
biomechanical), (d) organisational/management structure audit tools and (e) financial models of assessment.

Table 1. Outcomes (literature review).

Beneficiary Outcome No.
Staff (429) Staff competence 25
Staff competence (organisation) 3
Staff injuries 81
Staff knowledge skill 12
Staff perception 127
Staff use of equipment 14
Physical workload 153
Psychological well-being 5
Modified work 2
Number of staff 5
Carer perception 2
Patient (44) Patient perception 38
Patient result 6
Organisation (83) Financial 28
Incident/accident 8
Quality of care 1
Risk assessment 6
Staff absence 32
Training numbers 7
Audit performance 1
Task (32) PH techniques 10
Time for task 22
Equipment Equipment 8
Relative Relative perception 2
Total 598
 Ergonomics 1283

Table 2. Interventions strategies (literature review).

Intervention strategy
Organisational Risk assessment
Work organisation/practices changed
Feedback
Group problem solving/team building
Review/change of policies and procedures/safe systems of work
Discussion of goals with clients (patient)
Change/introduce patient risk assessment system
Introduction of hazard register
Audit of working practices/risk assessments
Patient handling supervisor, peer leader and local risk assessor
Management systems, change management and organisational structures
National regulation
Physical or engineering Equipment purchase or provision (including training)
Equipment design/evaluation
Equipment maintenance
Work environment redesign and space constraints addressed
Review staffing levels and increase staffing levels
Introduction of lifting team programme
Task analysis and job-design analysis
Change in uniforms
Personal Education and training
Injury monitoring and treatment, e.g. return to work
Physical fitness training
Stress management
Medical examination and lifting skill assessment

(a) Individual patient handling risk assessments and plans

(ACC Worksafe 2003; Fray et al. 1999; RCN 2001; Smith 2011)
(b) Physical environment risk assessments
(i) Criteria-based assessments
(ACC Worksafe 2003; Fray et al. 1999; HIT – Smith et al. 2005)
(ii) Residual risk scores/evaluations
(Care Thermometer – Arjo Ab 2007b; MAPO – Battevi et al. 2006)
(c) Individual observational tools for specific handling tasks
(i) Postural analysis tools
Most commonly reported were REBA (Hignett and McAtamney 2000) and OWAS (Karhu, Kansi, and
Kuorinka 1977).
(ii) Biomechanical assessment tools
High-technology instrumentation provides comprehensive analysis of biomechanical risks (Jäger, Theilmeier,
and Jordan 2008; Marras et al. 1999; Skotte 2001).
(iii) Exposure measures
In patient handling studies, both Knibbe and Friele (1999) and Warming et al. (2008) create models for
exposure based on logbook records.
(iv) Subjective appraisal measures
Many subjective assessments of a workers response to the task, e.g. Borg scales for the rate of perceived
exertion (Borg 1998), Likert scales for comfort (Nelson et al. 2006) and ease of use for equipment (Connelly
et al. 2001).
(v) Methodological observation tools
Simple checklist criteria were suggested by Alovosius and Sulzer Azarof (1985), Feldstein, Vollmer, and
Valanis (1990), Kjellberg et al. (2000, 1998), St. Vincent, Tellier, and Lortie (1989) and Engels, Brandsma, and
van der Gulden (1997). In part, Raine’s PER (2001) also fits these criteria. These question sets have seen some
development to give a more detailed analysis: Pate (Kjellberg et al. 2000); DiNO (Johnsson et al. 2004) and a
video analysis tool (Warming et al. 2004). The SOPMAS tool measures the competency and learning levels
required for task completion (Tamminen-Peter 2004).
(d) Organisational/management structure audit tools
1284 M. Fray and S. Hignett

The area of safety culture and organisational performance was represented by PHOQS (Hignett and Crumpton
2005) and MARCH (Smedley et al. 2005).
(e) Financial models of assessment
Not many studies formally identified the methods for financial comparison (Siddarthan, Nelson, and Weisenborn
2005; Smedley et al. 2005).
Although some of these methods above have been used for intervention trials and evaluated in validation studies
(Figure 2), there is very little overlap in the risks measured. These studies have shown a greater understanding for evaluating
outcomes of patient handling interventions, but the difficulty of comparing measures, results and recommendations across
interventions remains.
Multi-factorial interventions have been reported to be the most effective approach (Amick et al. 2006; Hignett et al.
2003; Nelson et al. 2006). In order to compare different interventions, there was a need for a single method to measure the
performance of a healthcare organisation when implementing an intervention strategy. This would allow PHP to evaluate
their intervention strategies, gain a clearer understanding of successes and failures and plan for future interventions.

Quality Tool
Financial evaluation
Organisation

Sickness absence
outcome

OH management
Organisational commitment MARCH
Patient handling safety
culture PHOQS
Hoisting equipment Care HIT
Quick scan
Thermometer
Task outcome

Other handling aids Care

MAPO

Quick scan
Thermometer
Environment provision
Care
Thermometer
Training provision
Physical outcome
measures Posture/exposure/biomechanics
Laboratory observation Posture/exposure/biomechanics
Staff outcome

Field observation
Compliance with safe
methods Pate/Warming (2008)
Video observation DiNO
Field observation
Skill levels and
competencies SOPMAS
Patient
Only subjective assessment criteria
outcome

Figure 2. Patient handling outcome measurement tools (Fray 2010).

2.2 Focus groups

Four countries from the European Panel for Patient Handling Ergonomics (EPPHE) were invited to participate (Finland,
Italy, Portugal and the UK). The countries represented a geographical and demographical spread (Table 3) and a range of
implementation dates for the EC directive on manual handling in healthcare (Hignett et al. 2007). Two additional
international expert focus groups (n ¼ 10) were carried out with participants from Belgium, Germany, Netherlands,
Australia and the USA, and English-speaking participants were recruited at international patient handling conference
symposia.
Each country had an international expert who acted as the local study facilitator and recruited participants (n ¼ 36) for
each focus group. They were asked to invite participants with experience in the management (including offering advice) of
patient handling issues in health or social services, either in hospital or in the community setting. The role of PHPs can be
taken by a range of professions and level of staff (ISO TR 12296 2012). All local facilitators (n ¼ 4) participated in one of
the two international expert groups to experience and learn the process and format. The lead researcher (M.F.) was present
at all the groups to ensure the standardisation of the process and assist with the development of the discussion topics during
 Ergonomics 1285

Table 3. Participating countries.

Population Hospital beds Implementation
Country (million)a Location per 100,000 populationb of EU directivec Patient handling system
UK 61.2 NW 330.2 1993 Well-defined job roles and documentation
Italy 60.5 SE 364.3 1994 Primarily in occupational health
Finland 5.3 NE 623.1 1994 Physiotherapy managed process
Portugal 10.6 SW 334.9 1993 Weaknesses in access to ergonomics support
a
Eurostat Year Book.
b
Eurostat Hospital beds.
c
Hignett et al. (2007).

the focus group with the local facilitator and interpreter. Each group was conducted in the native language with a local
facilitator and whispering interpreter to allow the researcher (M.F.) to follow the discussion and take field notes. Both the
focus group and whispering interpretation were audio-recorded.
The method for the focus groups was informed by the Nominal Group Technique, where participants record their own
thoughts based on a question set before and after group discussion (Higgins 1994). It was piloted was at two UK sessions.
The documentation was translated into Finnish/Italian/Portuguese (in the UK) and sent to the facilitator for translation and
comprehension checks.
Each focus group used a scenario describing the patient handling risks at a care facility with information about the work
organisation, patient care system and patient handling risks. Data were collected as:

(a) Generation of ideas, where the participants were asked to give advice to the facility to manage the patient handling
risks in the scenario and identify which outcomes they would like to measure.
(b) Recording of ideas with preferred outcomes documented individually by each participant at the beginning of the
focus group.
(c) Clarification of ideas, where the facilitators developed a discussion checklist to prompt the focus group as a review
of all the identified outcomes.
(d) Voting on ideas, where the participants ranked their preferred five outcomes.

Ethical approval was granted by Loughborough University Ethical Advisory Committee and, where required, additional
permissions were granted by the EU facilitator’s organisations. All participants signed for informed consent permissions.
The focus group audiotapes were translated by an independent service, transcribed and compared with the whispering
interpretation. The recorded written ideas (b) were translated during the meeting by the whispering interpreter and local
facilitator. All translated data were returned to the local facilitator to check for errors in language and translation. A
computerised qualitative analysis package (NVivo7) was used to code the data using a content analysis framework to
develop themes. A statistical analysis of the ranked priorities (d) from each focus group was undertaken to explore the level
of correlation between the different countries.
Reliability was addressed during data collection by the use of field notes as active observation, secondary observer field
notes, discussion of the field notes and transcription as soon as possible after the event, and journals of the coding formats
(Bryman 1988; Hammersley 1992; Kirk and Millar 1986; Spradley 1979). Silverman (2001) suggests that by addressing the
areas of constant comparison and comprehensive data treatment, a study design can demonstrate a high level of rigour. This
was achieved by:

. Allowing participants to create an individual set of preferred outcomes as the generation of ideas.
. Secondary selection of documented outcomes as the recording and clarification of ideas.
. Inclusion of all written outcomes in the discussion as the recording and clarification of ideas.
. Comparison of the discussion group transcripts and the ranked outcomes.
. Analysis of the UK pilot studies to compare health and social care.
. Comparison of four different EU sources.
. Comparison with the findings from the expert group (n ¼ 10).
. Comparison with the interventions and outcomes from the literature review.
1286 M. Fray and S. Hignett

Table 4. Outcome themes from focus groups.

Themes (n ¼ 20) Definition
Organisation Accidents and incidents The recording of incidents or accidents
from patient handling in a central
location as a performance measure
Absence or staff health Measures that record the time away
from work or lost productivity due
to MSD
Financial The financial impact of MSD in
an organisation against the costs of
any prevention programme
Training Measurements that define the delivery of
training, attendance numbers, duration and assessment
criteria
Risk management systems Specific interventions in the work place
to assist with the control of
patient handling situations, e.g. policy, risk
assessment systems, etc.
Satisfaction and image Measures relating to how the organisation
is perceived outside its organisation
Management commitment A measure of the support for
the prevention programme, managerially, financially and
organisationally
Staff MS health measures The measurement of the level of
MSD in the working population, injuries,
chronic conditions and fitness for work
Incidents and accidents Those staff who have been involved
in accidents, incidents or near miss
situations when patient handling
MSD exposure measures Physical workload factors that place the
staff under strain, forces, postures, frequency
of tasks and workload
Compliance, competence Measures of the staff’s individual behaviour to complete patient
transfers, skill, compliance with safe methods
and equipment use
Psychological well-being Measurement of the staff’s mental health status, measures of
stress, strain, job satisfaction, etc.
Patients Patient injuries Records of accidents or injuries to
patients when being assisted to move,
bruises, lacerations, tissue damage, etc.
Patient perception The subjective assessment of a patient
when being moved in transfers or
mobility situations, fear, comfort, etc.
Patient condition Does the patient handling method affect
the length of stay, treatment progression
and level of independence?
Quality of care When a patient is being moved
are all their requirements for dignity,
respect, safety, empathy and being met
Task Equipment available Is all of the appropriate equipment
being provided for the level of
care required?
Safety Is the method of moving an
patient meeting all the requirements for
safety, security and suitability?
Speed Any measurement that identifies the time
taken for patient handling, the rate
or speed of movement
All Safety culture Measurement of how the organisation behaves
and how its management systems can
be shown to control risk
 Ergonomics 1287

2.2.1 Focus group findings

Thirty-six PHPs participated in the four focus groups including nurses, physiotherapists, occupational physiotherapists,
occupational therapists and occupational physicians. The non-clinical participants (n ¼ 12) included an ergonomist,
occupational health and safety technician, safety officer, work inspector, and social care practitioners. The range was due to
the country differences, for example, UK educates PHPs to post-graduate level, Finland uses mostly occupational health
physiotherapists, Italy supports the role through occupational health physicians and Portugal had a mixed picture. Only five
participants had less than 2 years experience and 75% (n ¼ 27) had over 5 years experience.
The data from the focus groups were analysed for content and theme resulting in 210 outcomes. These were coded and
compared to define each theme (n ¼ 20; Table 4) and then grouped with the outcomes from the literature review.
The next stage refined the analysis to reduce the number of themes by:
. Removing themes measuring qualities (not outcome) of an intervention (equipment available and training
attendance) and/or identified by less than five participants (safety, speed, satisfaction and image).
. Combining all safety culture themes (risk management tools and improved systems, management commitment, and
safety culture) and themes relating to two beneficiaries (accidents/organisation and accidents/staff).
The ranked scores from the Voting on Ideas were combined with the thematic definitions to give a ranked outcome list
for each country and the combined expert scores (Table 5). The same 12 outcome themes were found to be the highest
ranked themes for each country.
There was similarity between the four EU datasets with safety culture, compliance and MSD measures as the highest
ranked outcomes and finance, and patient-related measures as the lower ranked outcomes. It was therefore more appropriate
to conduct an analysis for association rather than difference. Kendall’s Measure of Concordance was performed using the
correction factor for tied ranks and W ¼ 27.66 (n ¼ 12, df: 11, k ¼ 4) is significant at the 0.005 level, indicating close
agreement between the four groups.
As a comparison, the combined rankings of the four EU focus groups were compared with the combined rankings for the
two expert international groups. For these data, W ¼ 0.7882 (n ¼ 12, df: 11, k ¼ 2, x 2 ¼ 17.34), and the significance was
reduced to p ¼ 0.1. There were differences between the priorities of the international expert groups and the EU focus
groups. The five highest ranked outcomes (1 –5) were the same with minor differences in order but financial and accident
numbers outcomes showed different priorities. Due to these differences, the final ranked list was created using the EU focus
group data.
The tied rank between the outcomes of psychological well-being and patient condition was re-calculated using the total
votes for the two outcomes in the practitioner groups. This indicated that psychological well-being was preferred. The final
ranked list is shown in Table 6.

3. Results
The literature and focus group findings identified the outcome themes that were required to be measured in the TROPHI
process.

3.1 Creation and development of TROPHI

The creation and development of TROPHI followed a step-wise process. The focus group data ranked the 12 outcomes that
were valued by PHPs. The systematic literature review identified a range of measurement methods for each of the preferred
outcomes. These were combined to create TROPHI V1.
TROPHI V2 was developed after a trial at two UK hospital sites (acute and community) to explore the availability of
data and time required for data collection. These data were discussed together with the data collection methods, scoring
systems for each outcome and guidebook at an expert UK review panel (n ¼ 9) with representatives from the Health and
Safety Executive, National Patient Safety Agency and National Back Exchange. The comments were incorporated into
TROPHI V3, including the supporting guidebook and training for data collection, inter-rater reliability assessment and a
spreadsheet for calculating the score tables. The data collection format was rationalised into four sections for V3; a
management survey about workload and staff structure, a safety culture audit, observations of patient handling transfers for
25% of patients and a questionnaire survey for 50% staff and 25% patients.
TROPHI V3 was translated into the three EU languages and checked by the translator and the EU group facilitators for
terminology and language differences. Several explanations, definitions and descriptors were changed before the EU trials.
Full datasets were collected (with M.F. in attendance) using TROPHI V3 from two wards in each of the four EU countries,
with local facilitators asked to select wards demonstrating expected good and poor performance. As each measure had a
1288 M. Fray and S. Hignett

Table 5. Ranked themes.

Outcome theme Italy Portugal Finland UK EU rank Expert rank
Organisation Accident numbers 8 3 11 6 6 12
Absence or staff health 3 8 2 4 4 2
Financial 12 12 7 10 12 6.5
Safety culture 2 1 1 2 1 4.5
Staff MS health measures 1 5 8 1 2 3
MSD exposure measures 12 9 5 12 10 6.5
Competence and compliance 4 2 4 6 3 1
Psychological well-being 10 7 9 4 7 9
Patient Patient injuries 8 12 11 9 11 8
Patient perception 8 10 11 8 9 10
Patient condition 6 7 6 11 8 12
Quality of care 5 4 3 7 5 4.5

different scoring system (parameters) and different values for acceptable and unacceptable levels of performance, the first
datasets were reviewed to ensure that differences between areas were detected.
A final review was carried out by EPPHE members (including academics and industry representatives, n ¼ 16) from
eight countries. Each participant received the final version of TROPHI V3 including the measuring and scoring system in
advance to allow a full discussion of each section during the 2-day meeting.

Table 6. Rank order of preferred outcomes.

Theme (outcome)
Safety culture
MS health measures
Compliance and competence
Absence or staff health
Quality of care
Incidents and accidents
Psychological well-being
Patient condition
Patient perception
MSD exposure measures
Patient injuries
Financial
No. of outcome
Definition measures
A measure of organisational behaviour and how its management systems control 5
patient handling risk. This is an audit of procedures rather than behaviours, e.g.
policy, risk assessment, records of training, etc., and should measure the support
for the prevention programme both financially and organisationally
The measurement of the level of MSD in the working population, injuries, chronic 45
conditions, fitness for work, staff turnover, work capacity, etc.
Measures of the staff’s individual behaviour to complete patient transfers, 21
competence, skill, compliance with safe methods and equipment use
Measures that record the time away from work or lost productivity due to MSD, 19
days/shifts lost, staff on reduced work capacity and staff turnover
When a patient is being moved are all their requirements for dignity, respect, safety, 1
empathy, being met
The recording of incidents, accidents or near misses from patient handling where 2
staff could have been injured in a central location as a performance measure
Measurement of the staff’s mental health status, measures of psychological stress, 8
strain, job satisfaction, etc.
Does the patient handling method affect the length of stay, treatment progression 1
and level of independence?
The subjective assessment of a patient when being moved in transfers or mobility 26
situations, fear, comfort, etc.
Physical workload factors that place the staff under strain, forces, postures, 170
frequency of tasks and workload measures
Records of incidents, accidents or injuries to patients when being assisted to move, 0
bruises, lacerations, tissue damage, etc.
The financial impact of MSD in an organisation, lost staff time, lost productivity 10
costs, compensation claims, litigation, all direct and indirect costs against the
costs of any prevention programme

3.2 Selection of scoring methods for TROPHI

The methods for measuring each of the 12 outcomes were selected from published validation studies or used in intervention
studies as far as possible (Table 7). Some outcomes were well represented, particularly the biomechanical exposure
methods and musculoskeletal injuries, but others had very few published methods. None of the published tools were
 Ergonomics 1289

Table 7. Outcome measurement tools used for TROPHI.

Preferred outcome
1. Safety culture
2. MS health
3. Competence/compliance
4. Absence or staff health
5. Quality of care
6. Accident numbers
7. Psychological well-being
8. Patient condition
9. Patient perception
10. MSD exposure measures
11. Patient injuries
12. Financial
Outcome measurement tool Source
Organisational audit of safety systems (PHOQS) Hignett and Crumpton (2005)
MSD level in staff (Nordic Questionnaire) Dickinson et al. (1992)
Observational checklist (DiNO) Johnsson et al. (2004)
Standard absence per work population (OSHA) Charney (1997)
Ward and patient survey to evaluate Nelson et al. (2008)
care quality
Accident numbers and non-reporting ratios Menckel et al. (1997)
Three part worker survey for satisfaction Evanoff, Bohr, and Wolf (1999)
and well-being (Bigos)
Patient survey to evaluate clinical needs Nelson et al. (2008)
Survey for comfort, security, fear, etc. Kjellberg, Lagerstrom, and Hagberg (2004)
Workload based on patient handling tasks Knibbe and Friele (1999), Arjo Ab (2007a, 2007b)
Measure for detrimental effects of poor No source
handling
Calculation of costs versus investment Chokar et al. (2005)

changed, but some additional data were required to satisfy the theme definition (Table 8). For example, the safety culture
measure (PHOQS tool; Hignett and Crumpton 2005) had an added score for management commitment from staff and
managers; competence and compliance (DiNO; Johnsson et al. 2004) required a comparison of the observed transfer with
the documented risk assessment to assess compliance; the MSD exposure measure (Care Thermometer; Arjo Ab 2007b)
recorded the number of uncontrolled transfer risks in the location, so additional risk factors were added for plus size patients
and behavioural difficulties. No published measurement methods were found for the patient perception and quality of care
outcomes, so simple subjective assessments were developed for the patients. The financial outcome was simplified to a
binary score signifying positive return on investment. Full copies of TROPHI and the guidance for completion are available
from the author.

3.3 Evaluation of TROPHI

The range of scores for each section of TROPHI was clarified with the results from the trial to improve differentiation across
the sites (Table 8). The data collection time per area was less than 3 h.
The evaluation results (Table 9) are shown as the percentage scores for each section and the total combined score (%).
They show differentiation between the wards and management systems across the different outcome scores, for example,
UK2 site had one staff member on reduced capacity for 12 months, Portugal (Po1 and Po2) scored poorly for compliance
and MSD exposure due to poor equipment provision and high risk tasks. Italy (It2) received the highest overall score.
However, a tendency for averaging was seen in the total scores. During the evaluation, some data were not available and an
appropriate maximum or minimum score was inserted. A cost– benefit analysis was not conducted as none of the sites had
access to sickness absence costs.

Table 8. Range of outcome scores (%).

Preferred outcome Description (contribution to total) Data collection Range 0% 100%

Safety culture Modified PHOQS score (12)* Safety culture audit 0 to 120 0 120
MS health measure Average of MS health in staff (11) Staff questionnaire 0 to 6 .5 ,1
Competence/compliance Mean modified DINO score (10)* PH observation 0 to 16 ,4 16
Absence or staff health Standardised lost work time (9) Organisation review 0 to 100,000 20,000 0
Quality of care Mean PH quality score (8)* Patient questionnaire 0 to 4 0 4
Accident numbers PH accidents per staff (7) Organisation review 0 to 4 .1 0
Psychological well-being Mean well-being score (6) Staff questionnaire 0 to 1 0 1
Patient condition Mean assessment of PH system (5)* Staff questionnaire 0 to 1 0 1
Patient perception Mean patient perception score (4) PH observation 24 to þ4 ,0 4
MSD exposure measures MSD exposure (workload/patient) (3)* Organisation review 0 to unlimited 4 0
Patient injuries Patient injury ratio per bed per year (2)* Organisation review 0 to not known .4 0
Financial Standardised cost improvement (1) Organisation review Loss to savings Any loss . £ 1 saved
Total 78 as %

*Additional data were added to original published tool.

1290 M. Fray and S. Hignett

Table 9. EU trials (% scores).

UK 1 UK 2 Po 1 Po 2 Fi 1 Fi 2 It 1 It 2
Safety culture 55.6 46.7 13.8 23.3 30.7 39.8 15.6 25.2
MS health measures 40.0 50.0 55.0 51.5 22.6 21.6 38.5 100
Compliance/competence 29.2 47.9 3.5 11.5 59.6 29.3 56.9 29.6
Absence or staff health 0.0 10.7 95.9 64.6 71.2 0.0 100 99.5
Quality of care 75.0 80.0 100 69.0 64.2 86.7 88.8 79.5
Incidents and accidents 0.0 97.3 89.5 69.8 82.5 72.0 89.8 88.5
Psychology well-being 76.2 82.4 77.7 70.7 75.0 70.3 71.7 81.2
Patient condition 64.5 79.9 45.0 65.9 64.2 62.5 69.1 84.4
Patient perception 68.7 100 100 66.7 100 52.1 93.3 90.0
MSD exposure measures 64.0 70.8 52.1 55.2 79.4 75.8 71.6 97.1
Patient injury 0.0 0.0 91.8 66.8 100 100 100 100
Financial 100 100 100 100 100 100 100 100
Combined % score 38.5 53.0 53.2 46.0 53.5 42.3 58.4 65.6
Note: Italic values indicate that an appropriate maximum or minimum score was inserted as data were not available.

4. Discussion
Patient handling interventions have focused on musculoskeletal injuries and their financial cost due to many reasons,
including legislation, litigation and insurance, etc. The difficulty of evaluating ergonomics interventions in the quickly
changing environments of healthcare provision has been recognised for some time (Straker et al. 2004) and several reviews
have indicated that multi-factorial interventions for patient handling offer the most effective approach (Amick et al. 2006;
Hignett et al. 2003). Recent studies support the use of multifaceted ergonomic programmes to improve risk management for
patient handling (Berthelette et al. 2012; D’Arcy, Sasai, and Stearns 2012; Gucer et al. 2013; Lim et al. 2011; Szeto et al.
2013). The discussion of this study is presented in sections to cover the results of the development of TROPHI, the possible
limitations and actions for the future.
Some outcomes may have effects on other outcomes (Figure 3), which raises the level of their contribution to the overall
score. Safety culture (1) interacts with all other groups, whereas financial analysis interacts with no other outcomes which
may explain the order of the priority rating. Other high-priority outcomes showed higher levels of interaction and indicated
group behaviour; competence and compliance (3), quality of care (5) and accident numbers (6) all had effects on eight or
more other outcomes. Several outcomes interacted with four to six others: MS health measures (2), psychological well-
being (7), patient condition (8), MSD exposure (10) and patient injuries (11). Placing a high priority on a financial outcomes
will probably only be achieved with good performance in all the other outcomes, and interventions aimed at (1), (3), (5) and
(6) will probably give the best return. Recording a positive return on the financial outcome will not necessarily translate to
positive score in any other outcome score though MSD sickness absence may be improved to account for financial values.
The effect of these interactions may influence the selection of interventions to improve the overall TROPHI performance.
In its present form, TROPHI delivers two sets of scores, 12 individual section scores and a total score. The ranking
process only allowed a simple 1– 12 score to be assigned to the 12 sections. The weightings and calculation structure will
need to be part of any future evaluation and validation. The final review indicated as much interest in the section scores as
the total, so there may be opportunities for the future use of TROPHI by focusing on specific improvements in individual
sections, whilst maintaining the scores in other sections.
There seems to have been a move towards more organisational and behavioural focus, with safety culture and
competence/compliance featuring alongside the traditionally measured MSD and sickness absence. This shift of

Organisational Measures of safe Measures of Financial

behaviour or quality effects on outcomes
measures behaviour individuals (12)
(1) (3,5,6) (2,4,7,8,9,10,11)

Figure 3. Outcome interactions.

 Ergonomics 1291

perspective may suggest that PHPs consider equipment/engineering solutions to be available for most scenarios and those
future interventions should focus on delivering organisational compliance.

4.1 Limitations
TROPHI was created to collect a comprehensive set of data from a ward or unit and calculated 12 individual section scores
and an overall score to measure the effectiveness of interventions for patient handling as a pre –post intervention
comparison or for inter- and intra-agency comparison.
This study investigated the range of outcomes that PHPs considered important for interventions. The ranked list showed
that musculoskeletal outcomes (MSD exposure, MS health and sickness absence) are valued but that other outcomes need to
be considered, specifically patient outcomes. The paucity of literature on patient outcomes indicates that further research is
needed to explore how the provision of safe and supportive patient handling could improve the quality of care and patient
perception, injuries and condition (Gucer et al. 2013).
The use of a specific occupational group (PHP) may be an important factor in the process. Although the agreement
between practitioner groups was good, there were relatively small numbers of participants. There were some differences in
the rank order of the outcomes from expert and practitioner groups suggesting that if another professional group was used
(e.g. healthcare managers), a different rank order might have resulted. However, it is believed that in this study, the mix of
roles and responsibilities of the participants added to the validity of the outcomes and rankings.
The collection of the large number of content terms (n ¼ 210) during the focus groups developed clear theme definitions
(n ¼ 20) with the similarity of content indicating conformity across the PHP participants from EU focus groups. During the
data collection, there were concerns about differentiating between interventions and outcome measures. Some of the
outcomes described the qualities or quantities of an intervention rather than the outcome (Robson et al. 2007). Every effort
has been made to use high-quality measurement methods with the proven validation. The process of measuring and
comparing different types of patient handling interventions has been addressed with the development of TROPHI. The final
EU trials and EPPHE review panel recorded positive feedback for the use of a complex measurement tool as the way
forward to replace the single-factor evaluations concentrating on, for example, MSD exposure outcomes. The EPPHE
review panel suggested specific items for future investigation, including the age effects for the MS health, absence/staff
health and MSD exposure and how patient handling can optimise the quality of care and patient condition.

4.2 Future considerations

TROPHI has incorporated a range of cultural differences in its development, but it is recognised that there may be
organisational, national and individual differences (Kay, Glass, and Evans 2012; Myers et al. 2012), barriers to
implementation (Koppelaar et al. 2013) and differing levels of compliance (Berthellete et al. 2012). These differences may
be represented in the complex score system of the tool but further comparison studies are required, e.g. safety culture and
climate (e.g. Sexton et al. 2011) or comparison with measures of best practice system implementation (e.g. Repestro et al.
2013). This should coincide with the development of a database representing a larger use of locations, healthcare sectors
and organisations to further understand the scoring systems and the effects observed in the combination and section scores.

5. Conclusion
The outcomes that PHPs perceived as important for patient handling interventions showed many similarities but also
considerable breadth and depth. Musculoskeletal outcomes featured strongly but were not the entire focus with staff,
organisational and patient outcomes all perceived as important. Patient outcomes were recognised as important, but little
research was found to measure these outcomes. Further investigation is required to quantify the quality of patient handling
performance by measuring the improvement in patient care as this can and add value to the healthcare industry.
TROPHI has been used successfully in four EU countries to collect data and is able to detect differences in patient
handling performance from the scores in the 12 sections and an overall performance score for patient handling
interventions. This will allow future interventions to be designed to achieve specific outcomes and create opportunities for
more directed interventions to enable best return on financial investment.

Acknowledgements
We are very grateful to all participants in the workshops and our colleagues in the European Panel on Patient Handling Ergonomics
(EPPHE) who collaborated in this project. In particular, we would like to thank Leena Taminen-Peter (Finland), Natale Battevi and Olga
Menoni (Italy), Teresa Cotrim (Portugal) and Clare Mowbray (UK) for arranging access to sites and colleagues in their respective
1292 M. Fray and S. Hignett

countries. This project was part funded by Arjo-Huntleigh ab. for the international travel and administration costs and both journal paper
and transcription translations. It was completed as part of a PhD programme at Loughborough University.

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