Moments of speaking and silencing: Nurses share their experiences of manual handling in healthcare

ARTICLE IN PRESS+ModelCOLEGN-237; No. of Pages 10

Collegian (2013) xxx, xxx—xxx

Available online at www.sciencedirect.com

ScienceDirect

j ourna l h omepage: www.elsev ier .com/ l ocate /co l l

Moments of speaking and silencing: Nursesshare their experiences of manual handlingin healthcare

Kate Kay, RN, Crit Care Nsg Cert, BSc (Behav) ∗,Alicia Evans, RN, Cert Psych Nsg, BN, Grad Cert Higher Ed,MBA, PhD,Nel Glass, RN, Dip Neuroscience Nsg, BA, MHPEd, PhD

Australian Catholic University, Locked Bag 4115, Fitzroy, MDC, VIC 3065, Australia

Received 9 September 2013 ; received in revised form 6 November 2013; accepted 17 November 2013

KEYWORDSCritical methodology;Emancipatory;Manual handling;Power relations;Voicing

Summary Nursing care involves complex patient handling tasks, resulting in high muscu-loskeletal injury rates. Epidemiological studies from the 1980s estimated a lifetime prevalenceof lower back injuries for nurses between 35 and 80%. National and international studies con-tinue to mirror these findings. Despite the development of programs intended to reduce manualhandling injuries, sustainable solutions remain elusive.

This paper reports on a study of nurses speaking about their perspectives on current manualhandling practices. Qualitative research conducted in 2012 investigated nurses’ perceptionsand experiences relating to manual handling in the healthcare context and their participationin injury prevention programs. There were two research methods: semi-structured interviewsand researcher reflective journaling. The research was framed in critical emancipatory method-ology. Thirteen nurses from two Australian states participated in the study.

Thematic analysis revealed an overarching theme of ‘power relations’ with a subcategoryof ‘(mis)power’ that comprised two subthemes, these being ‘how to practice’ and ‘voicingpractice issues’.

Specifically, this paper explores nurses verbalising their views in the workplace and responseswhich left them feeling silenced, punished and disillusioned. The findings suggest that the socio-

Please cite this article in press as: Kay, K., et al. Moments of

manual handling in healthcare. Collegian (2013), http://dx.do

political context within which nurses practice impacts upon their ability to voice concerns orideas related to manual handling. Inclusion of nurses in the manual handling dialogue may gen-erate an expanded understanding of, and the potential to transform, manual handling practicesin healthcare environments.© 2013 Australian College of Nu

∗ Corresponding author. Tel.: +61 431 70 4532.E-mail address: [email protected] (K. Kay).

1322-7696/$ — see front matter © 2013 Australian College of Nursing Ltd. Published by Elsevier

http://dx.doi.org/10.1016/j.colegn.2013.11.005

speaking and silencing: Nurses share their experiences ofi.org/10.1016/j.colegn.2013.11.005

rsing Ltd. Published by Elsevier Ltd.

Ltd.

dx.doi.org/10.1016/j.colegn.2013.11.005


http://www.sciencedirect.com/science/journal/13227696

www.elsevier.com/locate/coll

mailto:[email protected]


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ARTICLEOLEGN-237; No. of Pages 10

ntroduction

his paper presents a dataset from a recent qualitative studyn manual handling in healthcare. The research was situatedn the critical paradigm and the findings highlight the impor-ance of including nurses’ perspectives in the dialogue thatnforms approaches to manual handling injury prevention inhe healthcare sector.

The paper begins with an overview of the context foranual handling, specifically noting the historical margina-

isation of nurses in the management of manual handlingssues. The major component of the paper follows, this being

discussion of the data associated with power relations andhe challenges embedded within voicing practice issues.

anual handling

anual handling has been variously defined as actions thatequire the application of force to perform a particular taskr task sequence. Whilst the precise definition varies accord-ng to national and international jurisdictions, the commonhread is that of physical activity associated, but not con-ned to, lifting or moving objects or people in some mannerASCC, 2007; Garg & Kapellusch, 2012; Hignett et al., 2007;SE, 1992; Iakovou, 2008; WorkSafe Victoria, 2000). Therovision of nursing care to patients in healthcare facili-ies necessarily entails manual handling and hence is anntegral part of nursing practice (Holman, 2006; Retsas &inikahana, 2000). Research conducted over many years haset to firmly resolve ongoing issues regarding injuries tolinicians consequent to manual handling activities. In par-icular, disproportionately high injury rates exist within theursing and allied health professions (ASCC, 2009; Cromie,obertson, & Best, 2000; D’Arcy, Sasai, & Stearns, 2012).

njuries from manual handling

usculoskeletal disorders (MSDs) comprise a broad range ofnjuries that arise from manual handling actions. The aeti-logy of MSDs is multifactorial thus potentially confoundinghe direct identification of causal links for MSDs and theecognition of actions required to prevent their develop-ent (Punnett & Wegman, 2004; Yassi & Lockhart, 2013).espite the external validity threats arising from pre- andost-research designs, some case study findings suggest that

causal relationship between manual handling and MSDs isikely (Charney et al., 2010). Punnett and Wegman (2004)osited that ‘‘an international near-consensus’’ (p. 19) haseen reached regarding the risks associated with repetitiveovements, forceful exertions, non-neutral body positions

nd exposure to vibrations. On this basis, widespread devel-pment of guidelines and policies premised upon ergonomicrinciples for MSD prevention has ensued (ASCC, 2007;ignett et al., 2007; HSE, 1992; WorkSafe Victoria, 2000).

An exception to the ‘‘near-consensus’’ (Punnett &egman, 2004, p. 19) was a review by a Canadian group



f medical specialists and researchers that disputed asso-iations between assisting patients and the developmentf low back pain (Roffey, Wai, Bishop, Kwon, & Dagenais,010). Their findings have been heavily criticised by other

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esearchers due to contentious design issues (Yassi &ockhart, 2013).

SD prevalence in healthcare

SDs occur in response to either a specific incident or alter-atively as a result of cumulative damage over extendedime periods. Musculoskeletal trauma that is not immedi-tely apparent results in delayed recognition and treatment.he inability to link cumulative injuries directly to spe-ific events further hinders an understanding of injuryausality and therefore the development of effective injuryrevention strategies (ASCC, 2006; Burdorf, Koppelaar, &vanoff, 2013). Challenges in MSD detection and diagnosis,imitations on injury claims and cultural influences that dis-ourage injury reporting, all contribute to inaccuracies inSD prevalence data for the healthcare workforce (ASCC,006; Menzel, 2008; Safe Work Australia, 2009).

Despite potential underestimations, the prevalence andersistence of MSDs in healthcare has raised serious con-erns internationally. An extensive and seminal review ofhe international literature by Buckle (1987) had a combinedample of 3912 nurses and suggested an annual low backnjury rate of 40—50%. International studies consistentlyenerate similar findings. Recent cross-sectional studies inustralia with high response rates have confirmed Buckle’sndings and estimate that 95.5% of nurses will suffer an MSDuring their professional lives (Mitchell, O’Sullivan, Burnett,traker, & Rudd, 2008). Findings from other well-designedustralian studies endorse these estimates and have foundomparable injury rates amongst student nurses (Mitchellt al., 2008; Retsas & Pinikahana, 2000; Smith & Leggat,004).

arginalisation of nurses’ manual handlingxperiences

edical advances and the centralisation of healthcare haveltered the structure of nursing work and increased the man-al handling workload for nurses. However the potentialmpact of these developments received little attention untilhe emergence of MSD symptoms within the nursing work-orce (Collins & Menzel, 2006). This prompted the educationf nurses in ‘good body mechanics’, an approach devoid ofmpirical evidence, alongside judgements about the com-etency and integrity of injured nurses (Collins & Menzel,006; Garg & Kapellusch, 2012).

Medical and educational paradigms have continued toominate manual handling injury prevention strategiesCharney et al., 2010; HSE, 2007; Koppelaar, Knibbe,iedema, & Burdorf, 2013). Locally and globally, nurses havead minimal input into prevention programs and the contex-ual influences on nurses’ manual handling practices haveeen largely overlooked (Kay, Glass, & Evans, 2012). Theistorical subordination of nurses’ manual handling experi-


nces demonstrates the need for an investigation of nurses’erspectives on manual handling, highlighting any socio-olitical factors that influence manual handling practice inhe complex healthcare environment.


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Moments of speaking and silencing

Research overview

This paper reports a data set from a recent qualitativeresearch study. The aim of the study was to explore nurses’perceptions and experiences relating to manual handlingtasks associated with the direct care of patients. The studywas also designed to investigate the nurses’ experiences,beliefs and attitudes pertaining to injury prevention pro-grams.

Method

Research design

Qualitative inquiry assumes that knowledge is relativeand context-dependent, valuing people’s subjective expe-riences, intentions, ideas and emotions throughout theresearch process (Taylor & Roberts, 2006). Consistent withthe epistemology of qualitative research designs, this studyaimed to explore human knowledge using the methods ofsemi-structured interviews and researcher reflective jour-naling.

A critical emancipatory methodology was selected toexplore the socio-political structures that impact uponnurses’ manual handling practices. Key objectives were toconduct research ‘with’ rather than ‘on’ participants andto provide opportunities for transformation (Rose & Glass,2008). Aligned with critical epistemology, the explicit inten-tion of this study was to generate knowledge that has thepotential for emancipation from relevant oppressive struc-tures (Fay, 1987; Roberts, DeMarco, & Griffin, 2009; Rose &Glass, 2008; Taylor, 2006).

Critical realism, based on the tenets of critical theory,was also incorporated into the research design (Wilson &McCormack, 2006). Critical realism acknowledges the socialdimensions of knowledge and the influence of context onoutcomes (Parlour & McCormack, 2012). This was an impor-tant aspect of the research that also has been used byother scholars to analyse complex social healthcare systems(Angus & Clark, 2012; Clark, Lissel, & Davis, 2008; Porter &O’Halloran, 2012).

Research questions

The research questions were:

1. What are the beliefs, attitudes and experiences of nursespertaining to manual handling?

2. How do nurses perceive their knowledge of manual hand-ling and safe practices is received by other health careprofessionals?

3. How can nurses’ knowledge of manual handling be incor-porated into the development of interventions to reduceinjuries?

Ethical considerations



Formal ethics approval was obtained from the universityHuman Research Ethics Committee prior to the recruitmentand data collection phases. The concepts of research merit,

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espect, justice and beneficence were at the forefrontf the study, in accordance with the belief that researchthics comprises an ongoing, dynamic process rather than aingle event of institutional approval (National Statementn Ethical Conduct in Human Research, 2007). Informed,oercion-free consent was obtained initially and renegoti-ted when required throughout the study.

ata collection and analysis

otential participants were recruited via notices in profes-ional journals, announcements at professional conferencesnd associations, professional contacts and snowballeferrals from nurses who participated in the study. Semi-tructured interviews were undertaken in 2012 with 13egistered nurses currently employed in acute or aged careacilities in Victoria or Tasmania, Australia. An overviewf the demographic details of participants is provided inable 1. In addition to pseudonyms given to all participants,heir ages have been reported here according to age group torevent potential identification of any individual. The pre-ise age range of participants was from 25 and 64 years.ive had university bachelor degrees in nursing and the oth-rs had certificate based nursing qualifications. Interviewsook place in the participants’ homes or at a location ofheir choice and ranged from 61 to 132 min, with an averageuration of 85 min.

The second method for the study was researcher reflec-ive journaling. Whilst journal entries provided an additionalource of data for the study, this method was also adopted toacilitate rigour (Holloway & Biley, 2011). Reflective journal-ng is frequently incorporated into critical research designso promote researcher reflexivity and ensure transparencyf process (Mantzoukas, 2005; Rose & Glass, 2010). Reflexivenalysis of the researcher’s potential influence on the dataollection process recognises the impact that personal androfessional values, beliefs and experiences can have on thendings (Jack, 2008).

It is imperative that critical researchers reflect on theirwn processes and how they engage with the research andhe participants. The first author had professional expertisen nursing and manual handling for several years prior tohe study. The participants were all aware that the inter-iewer’s clinical experience was the impetus for this studynd that she had actively separated from former profes-ional roles whilst undertaking this postgraduate researchroject. In this way the role as a graduate student researcheras emphasised. It was also explained that whilst famil-

ar with generic aspects of manual handling in healthcare,he researcher’s focus was on the thoughts and experiencesf each participant rather than assuming an understandingased on the researcher’s own background.

Congruent with the critical paradigm, data analysis wasot confined to interview transcriptions alone. Aspects ofnterviews beyond the spoken word were also includednd analysed as possible indicators of marginalisation. Forxample, the researcher observed and recorded in her


eflective journal the participants’ silences, pauses, bodyanguage, gestures and facial expressions and then reflectedn these occurrences along with articulated thoughts andeelings.



4 K. Kay et al.

Table 1 Interview participant demographics.

Pseudonym Agegroup

Highest nursingqualification

Workplacelocation

Facility Recruitment source

Alex 50—59 Hospital certificate Victoria —regional

Public Snowball referral

Dominique 50—59 Bachelor degree Tasmania Public Professional journalnotice

Jessie 60—69 Hospital certificate Tasmania Public Referral

Harley 50—59 Hospital certificate Victoria —metropolitan

Private Referral

Koh 50—59 Hospital certificate Victoria —regional

Public Conferenceannouncement

Quinn 20—29 Bachelor degree Victoria —metropolitan

Private Referral

Lu 50—59 Bachelor degree Victoria —regional

Public Snowball referral

Jamie 40—49 Hospital certificate Victoria —regional

Public Professional associationannouncement

Chris 40—49 Bachelor degree Victoria —regional

Public Conferenceannouncement

Riley 40—49 Hospital certificate Victoria —regional

Private Referral

Pat 20—29 Bachelor degree Victoria —metropolitan

Public Referral

Casey 30—39 Hospital certificate Victoria —metropolitan

Private Referral

Dakota 60—69 Hospital certificate Victoria —me

Private Professional association

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A modified version of Braun and Clarke’s (2006) thematicnalysis was utilised as the framework for data analysis. Thenalysis for the current study was developed by first iden-ifying key aspects of the data, followed by the utilisationf a critical lens to explore participants’ thoughts and expe-iences of being marginalised, silenced and/or oppressed.hemes were then developed and integrated during the finalnalytical stages. Table 2 displays the phases identified inraun and Clarke’s (2006) thematic analysis and their corre-ation with the analytical stages undertaken in the currenttudy.

Preliminary analysis involved listening repeatedly to thenterview recordings. In conjunction with data drawn fromhe researcher’s journal reflections, the initial key aspectsf the data were identified. Full transcription was thenndertaken to allow comparison with the aspects iden-ified by auditory analysis. The findings were congruentcross the auditory and written stages of preliminary anal-sis. Although Table 2 presents a sequential path, analysisntailed a dynamic and iterative process of moving back andorward between stages. Emerging aspects within the datauided re-viewing of other interviews and revisiting earliertages. The data was then reviewed through the lens of crit-cal realism, incorporating and integrating the key tenets ofritical social science in the final stages of analysis. Criti-



al realism is not in itself a method, but can be effectivelysed to guide inquiries by looking at contextual influ-nces such as social structures as well as individual agencyClark et al., 2008).

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A specific example is presented here to demonstrate theata analysis process utilised in this study. Stage 1 was char-cterised by repeated listening to an interview and reviewf reflective journal entries pertaining to that interaction.oncerns about Pat’s dissatisfaction with unresolved man-al handling issues were noted in her comments such as‘what exec don’t know doesn’t hurt them’’ and ‘‘so . . . thatxec [management] don’t find out about it so that we caneep doing what we are doing. . .’’ A journal entry by theesearcher after this interview noted:

A preferred technique had been developed in this work-group, but this was actively hidden from outsiders andPat and her colleagues are worried about detection. Itseems that Pat believes they have found a better way,yet Pat lowered her voice when these deviations werediscussed, stating ‘‘I know, it’s bad’’ and averting hergaze from the researcher.

Stage 2 comprised reflection on nurses choosing to ‘‘doheir own thing’’ when they found that manual handlingecommendations were unsuitable for their clinical envi-onment, in conjunction with the deliberate actions takeno prevent detection of alternate practices. Transcriptionn Stage 3 allowed review and reflection on this data,nd uncovered additional examples where Pat and her


olleagues experienced feeling punished, silenced or disil-usioned. Grouping of these aspects in Stage 4 uncovered

sub-theme of ‘voicing practice issues’ related to a majorheme of ‘(mis)power’.



Moments of speaking and silencing 5

Table 2 The data analysis process.

Braun and Clarke (2006) phase Stages in current study Analytical steps in current study

Phase 1 Stage 1Familiarising yourself with your data • Read reflective journal entries &

notes on non-verbal data• Listened and re-listened tointerviews

Review of reflective journalentries and deep immersion ininterview recordings

Phase 2 Stage 2Generating initial ‘codes’ • Reflected and assimilated verbal

and non-verbal aspects of data• Preliminary synthesis• Review of sample data byco-researchers to confirm analysisfindings

Realist analysis: identification ofkey aspects

Phase 1 repeated Stage 3• Transcribed and further listenedto interviews• Concurrently bookmarked keyaspects and researcher-reflectiveresponses

Transcription of interviews tovalidate initial aspects identified

Phase 3 Stage 4Searching for themes • Grouped identified aspects into

themes• Examined data for instances ofoppression, silencing ormarginalisation

Critical analysis: progression fromidentified aspects to thedevelopment of key themes &subthemes

Phase 4 Stage 5Reviewing themesPhase 5Defining and naming themes

• Reviewed in light of criticalrealism application to data• Searched for pertinent quotes• Additional theme identified

Alignment of realist themes withemergent critical themes

Phase 5 Stage 6Defining and naming themes • Integrated exemplars with

multilayered critical realismanalysis

Integration of critical analysis ofrealist experiences

Phase 6 Stage 7Producing the report • Generated research outputs:

wrote and presented findingsDiscussion, dissemination ofresearch findings at conferences,seminars and by journal

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Stage 5 progressed analysis to align these realist exam-ples with the emergent critical themes, in this case linkingcovert manual handling practices and fear of detection withmarginalisation and oppression. This was further highlightedby other parts of the interview where Pat perceived thatnurses were excluded from decisions about manual hand-ling policies and attempts to negotiate were seen as futile.Although Pat did not specifically use words such as oppres-sion, subjugation or silencing, these concepts were implicitin her explanations. Stage 6 of analysis progressed to a mul-



tilayered understanding of the reluctance to voice manualhandling concerns and the impact of power differentialsbetween nurses and organisational management on manualhandling practices. In this manner, an overarching theme of

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power relations’ was revealed and confirmed by integrationf realist experiences with critical analysis.

igour of analysis

he first author identified the key aspects of the datay means of deep immersion in the audio recordings.ubsequently these features were confirmed by theo-investigators’ independent reviews of six interviews.


eflexivity was used throughout all stages of the studyKitto, Chesters, & Grbich, 2008). As part of the iterativerocess, all participants were offered a copy of their inter-iew to enable member checking. All participants expressed


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atisfaction with their contribution to the study and noneished to alter, clarify or retract their comments subse-uently. Seven of the participants chose to accept a CDopy of their interview for their records although writtenranscriptions were offered if preferred. In contrast, all ofhe participants elected to receive a summary of the studyndings once available.

In the interim, a paper discussing the preliminary,nonymised findings was presented at a national conferencey the first author. This was attended by three of the partic-pants, unbeknown to the researcher prior to the session.fter the presentation, all three participants individuallyought out the researcher and conveyed their apprecia-ion regarding the manner in which the participants wereepresented in the study. One participant recognised herontributing comments in the quotations and specificallyhanked the researcher for this inclusion. Another chose toroudly declare her participation to a colleague in atten-ance. The participants’ feedback explicitly confirmed theiratisfaction with the fairness and accuracy of the reportedndings.

indings

he overarching theme of ‘power relations’ was identifieds fundamental to the participants’ experiences of manualandling. Power relations were often overlooked and notxplicitly identified by nurses in relation to manual handlingractices. In this study participants did not directly artic-late their oppression and the subcategory (mis)power wasdentified when a critical lens was used to analyse the verbalnd non-verbal data. (Mis)power comprised two subthemes,how to practice’ and ‘voicing practice issues’. The latterubtheme, discussed in this paper, consisted of three keyspects: ‘feeling punished’, ‘feeling silenced’, and ‘feelingisillusioned’.

(Mis)power indicates the perceived misuse or abuse ofower, explicitly or implicitly, in relation to participants’anual handling experiences. The prefix ‘(mis)’ implies the

se of something in the wrong way, or for the wrong purpose.or instance, the data provided examples of advice fromnjury prevention programs that did not transfer effectivelynto clinical settings due to physical or organisational con-traints; the exclusion of nurses from the manual handlingialogue; and participants’ perceptions of mismanagementf manual handling issues. The use of parentheses aroundhe prefix ‘mis’ denotes the less visible aspect of (mis)power.

The opportunity to voice manual handling concerns in thenterview setting facilitated some participants to create neweanings as a result of their reflections. For instance, somearticipants became aware of inconsistencies between safeandling directives and the absence of resources. Other par-icipants actively expressed plans for change upon returno their workplace, including goals to clarify or highlightreviously unacknowledged issues.

oicing practice issues



any of the participants were eager to speak of their man-al handling experiences and this was evident prior to,uring and after the interviews took place. For instance,

PRESSK. Kay et al.

pon meeting the researcher one participant noted ‘‘. . . hownusual it is [to be invited to speak]. Nurses aren’t usuallysked’’. Implicit in her tone and follow-up comments wasome dissatisfaction about the discounting of nurses’ feed-ack regarding practice issues. Furthermore, in response toormal expressions of appreciation sent within 24 h of inter-iew, all of the participants sent replies expressing theirratitude and offering further contact if clarification of theiromments was required.

Contrasting with a willingness to participate in thisesearch was a reticence to do so at times. Several par-icipants were momentarily hesitant to speak and in onenterview the audio-recording was ceased temporarily onequest. Another participant expressed interest but firstsked several pertinent questions about intentions for theesearch and confidentiality matters. Casey’s decision toarticipate was made after extensive telephone conver-ations totalling over 90 min. Chris travelled a substantialistance to be interviewed privately at a location distantrom the workplace, stating explicitly that ‘‘some peopleight not like what I say’’. This typified the commitment ofarticipants to speak of their manual handling experiencesnce their confidentiality was assured.

For clarity of presentation ‘feeling silenced’, ‘feelingunished’ and ‘feeling disillusioned’ are presented sequen-ially in this paper however, this is not intended to portray

linear process. The constructs of ‘feeling silenced’, ‘feel-ng punished’ and ‘feeling disillusioned’ can overlap, occurimultaneously or follow different sequences to the orderresented here.

eeling silenced

salient feature of ‘voicing practice issues’ was the aspectf participants feeling silenced and overlooked. Severalade unprompted statements referring, either explicitly or

mplicitly, to the concept of ‘voice’. Harley firmly statedhat ‘‘nurses don’t have a voice’’ after the interview hadnished. Another participant stated:

. . . we’ve always tried to have input I’m sure. I actuallywent to inspect this building . . . And I saw the problems. . . about 20 problems there and all this was listed [writ-ten down] . . . When I went [back] to have a look at it. . . the problems were still there. They hadn’t changedit. [pause] Nothing’s been changed . . . it’s still the same,so [pause] I don’t think anyone listens, or hears, I don’tthink so.

Alex, was chatting and laughing quite freely until theollowing statement:

. . . Yeah. Mmm. It’s quite interesting when you thinkabout it, isn’t it? Because yeah, we do have problems[pause]

Alex continued, whispering almost inaudibly:

. . . problems with manual handling.


Pat was much more direct about feeling silenced:

. . . you’re told what to do and that’s what you do. ‘‘Thenyou will not ask questions! You will not. . . . all thesethings are put in place and that’s what you must follow!


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And there will be no negotiation! You won’t ask questionsand we tell you what to do and that’s it!’’ Like, that’sit, there’s nothing else. . . . So if manual handling [policy]says that you don’t do that, you don’t do it. And that’s it.You know, it wouldn’t matter if you were to go and say. . . to somebody who had some influence ‘‘I don’t thinkthat works, I think this is better’’. [Their response wouldbe] ‘‘Oh, no, no, no. But this has been researched andit’s done, so that’s what we’re doing and that’s it!’’

Jamie’s comment regarding voicing and silencing isequally pertinent. In reporting the surprised reactions of col-leagues when a workplace issue was raised publicly, Jamieexplained:

They were more interested in ‘‘Why did somebody [speakup]?’’ . . . I heard people saying ‘‘Who said it? Why havethey said it?’’ That sort of stuff. . . . they didn’t agree ordisagree, they just thought . . . [in a quieter tone, mim-icking a bewildered colleague] ‘‘Somebody’s spoken upabout it!’’

Feeling punished

The experience of feeling punished was implicit through-out the participants’ narratives. Concerns about speaking ofmanual handling issues included avoidance of drawing atten-tion to themselves and their own practices. One explicitexample was offered by Alex when discussing nurses’ unde-clared concerns about manual handling:

. . . They [nurses] are hiding behind the fact that theydon’t know . . . Because they might get reprimandedbecause they don’t know.

When participants spoke about their concerns at work,they reported feeling punished by their employers, particu-larly if they disputed the suitability of the manual handlingprogram for the clinical environment. Participants spoke ofdismissive, aggressive or condescending replies and intima-tions of incompetency that discouraged future attempts toraise concerns.

Dakota graphically recounted the story of her attemptsto rectify manual handling issues in her workplace, she said:

. . . besides, . . . in support of a no-lift program, I havebeen intimidated, almost an incident of workplace bul-lying, ridiculed, vilified [by senior management]. . .

She later expanded by vivid re-enactment of an incident.During her disclosure, Dakota sat forward, shaking her fingervigorously only centimetres from the researcher’s face, withan agitated tone of voice. Later she appeared more subduedsaying:

No one apologised for the abuse . . . that I got . . . [Just]because I said ‘‘We should look at the suitability [of theprogram]’’.

Feeling punished was not confined to nurses’ criticisms



of manual handling programs. Most of the nurses inter-viewed noted reservations about the reporting of MSDs. Theyexpressed concerns about immediate and future employ-ment repercussions, in addition to anticipated negative

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udgements on their competency to perform manual hand-ing safely. One participant commented, when referring to

previous injury:

Mind you, I didn’t put in a Workcover claim because itwould probably put me out of a job . . . I just ‘suckedit up’ and kept going to work . . . you were pretty muchdemonised if you put in a Workcover claim.

Most of the participants reported instances where insuf-cient space, equipment or staffing levels prevented themrom practicing according to policy requirements. Quinnemarked:

Well, this is the frustrating, disheartening bit of it. It’slike ‘‘What do you do?’’ They’re not going to put anotherstaff member on because it’s going to cost more moneyto pay another person for a shift.

Another participant explained the actions that staff takeo appear to be complying with policy recommendations andvoid negative repercussions:

. . . if what they recommended was always practical, thenyeah, it would work. Then you’d do it. But sometimesit’s just not practical. Not all the time . . . So I think it’skind of like ‘‘Yeah you’re taught to do it this way, rah,rah.’’ We’ll follow that [when being observed] becausewe want to look like we’re doing the right things so wedon’t get reported.

eeling disillusioned

he aspect of ‘voicing practice issues’ most commonly ver-alised in interviews was that of ‘feeling disillusioned’.

Chris spoke extensively of an incident where nursing col-eagues were concerned about the level of physical strainhey felt whilst performing a particular task. Chris was dis-ppointed with the official response:

Well, I just thought ‘‘Hang on a sec . . . They didn’t evenlisten!’’ They really didn’t take it seriously . . . Yeah, Idon’t think they took it seriously . . . they just thoughtthat we were . . . causing trouble or something.

A colleague expressed disbelief but Chris replied suc-inctly saying ‘‘Well actually, I can [believe it]!’’

Jessie however, initially appeared satisfied with the over-ll management of manual handling at her workplace. Ashe interview progressed, some cynicism appeared, with theollowing offered repeatedly during the conversation:

. . . I can see they’re trying to cover their butts, that’swhy we have to do this.

Quinn reported discussions at a training program thatimilarly fostered feelings of disillusionment:

. . . people would ask questions . . . like ‘‘Ok, what do I dowhen I’m in a really small room?’’ [OHS officer’s responsewas] ‘‘Oh, well you won’t be able to do it.’’ [Quinn’svoice tapers off].


. . . Why are we not problem solving? Why are we nottrouble shooting? Why are we not taking this back to,you know, exec or admin [management] or whoever andsaying ‘‘This is a real issue’’? . . . So that it was just, sort


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of a handball . . . do an incident report which goes intoI don’t know what, and then you never hear back . . . ittells me that they don’t care about . . . their staff.

Many of the participants expressed indignation, frus-ration or anger when reporting how their opinions oruggestions were dismissed, devalued or ignored. Alex alsotated:

. . . But I’m also angry because it’s a [pause] . . . brandspanking new building so why wasn’t this all thought out?[pause] Because nurses don’t have the input.

Chris reported feeling ‘‘devalued’’ after frustrationsith the response to a manual handling issue raised by nurs-

ng staff and concluded that:

. . . it just proves they don’t listen to us, not interested inlistening, not interested in improving our working lives.

iscussion

anual handling is inherent in the provision of nursing careo patients. Risk prevention strategies to avoid MSDs haveistorically overlooked the inclusion of nurses’ input intohe development and implementation of interventions. Thessumption of adequacy of contemporary intervention pro-rams belies the persistence of high MSD rates within theursing profession. The dominant focus has been on ensur-ng nurses’ compliance with policy directives with deviationsn performance thought to explain manual handling injuriesClemes, Haslam, & Haslam, 2010; Hignett et al., 2003;oppelaar et al., 2013; van der Molen, Sluiter, Hulshof, Vink,

Frings-Dresen, 2005).In contrast with intensive efforts to implement

rgonomic-based interventions over recent decades,he socio-political aspects of manual handling in healthcareave received little attention (van der Molen et al., 2005).he researchers in the current study were acutely awaref the power, oppression and marginalisation issues thatmerged during the interviews. Data analysis revealed anverarching theme of ‘power relations’ with a subcategory(mis)power’. Whilst the theme of (mis)power has been dis-ussed earlier in this paper, the nature of ‘power relations’merged as descriptive of the power differential betweenurses and organisational management, and was describedirectly by one participant who stated ‘‘It sort of reiterateshe hierarchy . . . Oh, [nurses are] towards the bottom . . .

robably just above an orderly, and the technician, thenursing I think’’.

This study found that the nurses interviewed were reluc-ant to voice their opinions in their workplace about ongoinganual handling practice issues and intervention programs.

t was evident that the participants had concerns about theanagement of manual handling issues but they reported

hat their views about the workplace were rarely sought.he top-down decisions that directed manual handling pro-ram choices, policy development and enforcement ofompliance measures demonstrated the privileged use of



ower within the healthcare hierarchy.The majority of nurses reported that the advice provided

n training programs was not well suited for adoption inlinical settings and this confirms reports by other scholars

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Charney et al., 2010; Hignett, 2003; Koppelaar, Knibbe,iedema, & Burdorf, 2009). On initial questioning, all thearticipants verbalised agreement with the intentions ofanual handling programs to reduce injuries. However fur-

her probing by the researcher found that many participantselt frustrated when practice difficulties arose that wereot addressed by their employers. Several nurses expressednger at their exclusion from manual handling policy deci-ions.

Based on the data, the authors would argue that there is misdirected and inappropriate focus on demanding nurseso adapt their actions rather than the potential modificationf contextual factors. It could be postulated that the knowl-dge gained from this study could contribute to a broadernderstanding of manual handling issues and the develop-ent of future manual handling interventions.The findings of this study align with those of scholars

eporting the marginalisation and silencing of nurses inelation to other practice issues although there is scantesearch on silencing within the manual handling literatureElliott, Crookes, Worrall-Carter, & Page, 2011; Georges,011; Roberts et al., 2009). Whilst the broader literatureas discussed issues relating to speaking out, this study high-ights the consequences of voicing for nurses. The findingsuggest that feeling silenced, feeling punished and feel-ng disillusioned are aspects that are interwoven with onenother and contribute to the hesitancy of nurses to voiceheir concerns in the workplace.

tudy strengths and limitations

he findings were generated from the analysis of inter-iews with 13 nurses who self-selected to participate, inddition to researcher reflective journal entries. Reflex-vity was attended throughout the research process tooreground assumptions held by the researcher and ensureransparency, credibility and rigour. This study is representa-ive for the participants involved and cannot be generalisedo the wider nursing population. However, the findings alerthe reader to the complexity of manual handling issues inealthcare and the importance of context and socio-politicalnfluences.

onclusion

his study of nurses’ perceptions and experiences of man-al handling in healthcare aimed to explore the context forhe persistence of MSDs despite the introduction of injuryrevention interventions. The experiences and beliefs ofurses, previously overlooked in the development of manualandling programs, contribute to a richer understanding ofhe manual handling challenges in healthcare.

The major theme that emerged was that of ‘(mis)power’ithin an overarching meta-theme of ‘power relations’.he subtheme and data set discussed in this paper, ‘voic-

ng practice issues’, found that participants were feelingilenced, punished and disillusioned after attempts to speak


bout inadequacies in workplace manual handling programs.he new knowledge arising from this study was gainedhrough a focus on nurses’ perspectives in relation toanual handling. Their reported experiences highlighted


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socio-political constraints on manual handling practices inhealthcare. An increased awareness of the circumstances inwhich nurses practice facilitates opportunities to identifypotentially transformative actions that challenge the statusquo and empower nurses to improve their manual handlingcircumstances.

Acknowledgements

This research was partially funded through a post-graduatescholarship awarded to the first author, Kate Kay, by Aus-tralian Catholic University.

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Documents

Moments of speaking and silencing: Nurses share their experiences of manual handling in healthcare