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Ergonomic education for nursing students
ht. .I. Nurs. Szud., Vol. 30, No. 6, pp. 499-510, Printed in Great Britain.
1993 0
CW!O-7489/93 $6.@0+0.00 1993 Pergamon Press Ltd
Ergonomic education for nursing students ANNA-LISA HELLSING, R.P.T.” STEVEN J. LINTON, Ph.D. Department of Occupational Medicine. &ebro Regional Hospital, S-70185 tirebro, Sweden
BIRGITTA ANDERSHED, CHRISTINA BERGMAN, College
R.N. R.N.
qf Nursing iirebro, Sweden
MARGARETA
LIEW, R.P.T.
Departmenr of Industrial Ergonomy. Linkiiping University. Sweden
Abstract--An educational package of common ergonomic training as well as behavioural training was implemented in nursing education. The teaching methods also had the aim of increasing students’ awareness of the importance of total work environment for the prevention of back injuries. The experimental group was, on the whole, more pleased with their education than the control group. The experimental group judged their ability to analyse the work environment higher than the control group did. Observations in some practical worktasks showed that students from the experimental group worked in physically more favourable positions with less strain on the body.
Introduction
One of the biggest environmental
risks facing nurses is work-related back pain. Although
*Author to whom correspondence should be addressed.
499
500
A.-L. HELLSING
et al.
nursing experience may enable reduction of other risks such as work stresses, back pain normally increases in frequency with age. Even if we cannot expect to completely prevent back pain, the high occupational risk for nurses demands that interventions to diminish the risk as well as the consequences of injury be taken. Caring for sick people still means frequent and often heavy lifting (Gagnon et al., 1987). Occupational back pain and accidents related to lifting during care constitute a major risk for sick-listing among nursing personnel (Jensen, 1990; The Swedish National Board of Occupational Safety and Health). Learning correct use of body mechanics and lift technique is one main point. Another is to overcome obstacles that may hinder the use of correct techniques. The aim of this project was therefore to design, implement and evaluate an educational module within a nursing programme concerning the prevention of back and neck pain among nurses. Back pain in nursing Back and neck pain are common among the general population but increase when worktasks include heavy lifting or awkward work positions (Chaffin, 1978; Kumar, 1990). Those women with work consisting of frequent heavy lifting have twice the frequency of back pain compared with those with similar work but with less heavy lifting (Estryn-Behar et al., 1990). The overall prevalence of back pain is often reported to be 60-70% (BieringSorensen, 1989). The l-year prevalence of around 50% for nurses and nursing aides points to frequent relapses (Dehlin et al., 1976; Stappaerts, 1989). Stubbs (1983) found that 43% of those with back pain during the last year had had seven or more relapses. Another study of nursing aides showed the maximum frequency of back pain at the surprisingly low age of 20-24 years (Videman et al., 1984). These statistics suggest that nurses suffer their first back “injury” shortly after leaving nursing school and that once “injured” they will suffer periodic problems. Accidents causing back pain According to official Swedish statistics (The Swedish National Board of Occupational Safety and Health), nursing personnel is the professional group with the highest number of occupational accidents among women. Among women, over-exertion is the probable reason for one-third of the accidents. Over-exertion of the musculoskeletal system also results in a comparably longer sick leave than for other accidents: 45 days for women (1987) as compared to an average of 32 days for all work-related accidents. Aetiology for pain and accidents Lifts. The heavy or unexpected lift in an incorrect position is a common reason for back pain from occupational accidents. This is an excellent description of many of the situations that apparently occur in health-care. Accidents within a geriatric clinic for instance, were analysed by Lortie (1987) and it was shown that most accidents were related to patient transfer. These accidents caused longer sick leave periods than other accidents, particularly if the sick-listing was delayed by at least 3 days after the accident. Organization. Stress and work organization have recently been highlighted as key factors for successfully reducing the risk of injuries to the musculoskeletal system (Linton, 1990). Unrealistic expectations or unsafe situations often under time restraints are common in hospitals.
ERGONOMIC
EDUCATION
FOR NURSING
STUDIES
SO1
Patient lifting or transfer is apparently integrally connected to routines and the social climate at work. The nursing profession also involves a complex psycho-social environment where nurses must cope with high levels of physical (e.g. lifts), psychological (life or death) and social (work conflicts, patients, family demands) stress which often is unpredictable in terms of when, where and how intense the situation will be. All occupational accidents will not be preventable. The person affected needs prompt and active attention to recover as soon as possible and thereby reduce time off work (Donchin et al., 1990; Haig et al., 1990). Nurses’ ergonomic education
Licensed practical nurses receive a nursing degree after 2 years of additional nursing school education. The 2 years contain three theoretical blocks, which increase in specialization. Between and within the theoretical courses the students have supervised practice in different areas. Within these 2 years, 5 hours are devoted to nursing ergonomy. Although the exact content varies from school to school, this usually means anatomy, physiology and biomechanics as bases for understanding practical applications, e.g. patient transfers. Actual practice of transfers and lifting is, however, not included in this time. The role of the nurse in health-care is changing. Nurses today have a rapidly developing supervisory role and therefore need both knowledge and understanding to meet the usual demands of providing high-quality health-care as well as new demands as supervisory personnel. Wood (1987) has shown, for example, that supervisors’ active interest is of great importance in returning a person to work after an attack of back pain. In fact, maintaining positive contact had a greater effect than a back-school. Unfortunately, these facts do not seem to be highlighted during nursing education. Often the tradition of being a servant is a heavy burden on the nursing profession. Ideas about the project
If education is to help prevent occupational back pain the training ought to be introduced as early as possible during the basic professional training so that proper work techniques are developed. At the same time, work technique and organization do not seem to be given high priority among nursing students. Work technique, e.g. lifting and transfer, may not yet be looked upon as an important factor that can result in serious injury. Consequently, one aim of the study was to raise the students’ awareness of the importance of the total work environment for musculoskeletal problems. Another goal was to teach work routines and techniques so that the students would actually apply them at work. The basic assumption was that if students became more aware of the problem and learned as well as applied proper work routines and techniques, then occupational back and neck pain would be reduced. This paper reports on the development of an ergonomy education package for nursing students and the short-term effects of this education in terms of attitudes and behaviours. Methods
Overview of the design
Two nursing schools within the same geographical area participated, with one serving as the normal educational programme and the other as an experimental group where the ergonomy package was administered.
A.-L. HELLSING et al.
502
Procedure
Students in both schools completed an assessment at the start, half-way through and at the completion of their education and as a l-year follow-up. The teachers were free to implement their ideas about learning principles and also to add to this extra broad ergonomic education. Table 1 Subjects Number of persons Average age Average no of years of hospital work Experienced neck pain previous year Experienced back pain previous year
E-group
c-group
19 38 9 45% 55%
33 25 5 34% 59%
Control group
Students in the control group received the usual curriculum. The only change induced by the study was the assessment procedure. Extra education group
The extra education for the experimental group was integrated into the 2-year programme with an average of 2 hours of ergonomy per week. During the first semester (10 weeks) the extra education started with the theory and the practice of relaxation. Different methods were practised at rest, sitting and lying. Body awareness and basic correct biomechanics were practised both individually and in groups. Within the second semester the extra education started with a 2-day workshop where students were introduced to the ideas of physical and psychological training and also practised training. Subsequently the “traditional” ergonomic education started with practice in patient transferring techniques. The students also had some lessons and practice in pause gymnastics. The extra education in the third semester (40 weeks) contained lectures and discussions about pain-perception and physiology and how pain can be modulated by culture, expectations, social situations and psychological state. The importance of the psycho-social work environment was enlarged on with lectures, group exercises, discussions and homework. Models for coping with stress and pain were discussed and practised. The supervisors’ role in preventing injuries in addition to leading personnel was emphasized. The students wrote suggestions for preventive programmes towards musculoskeletal problems which they analysed during the following practice period. An intense 3-day course in technique for patient transfers was also conducted. At the end of their education the students also had teaching experience in instructing other personnel on the ward and the younger students. Assessment
Questionnaires
Both groups were asked to complete questionnaires. The first was a widely used standardized form from the Nordic Council of Ministers concerning musculoskeletal problems
ERGONOMIC
EDUCATION
FOR NURSING
STUDIES
so3
which they answered four times over the 3 years. The questionnaires have been tested for reliability and validity and shown to be acceptable (Kuorinka et al., 1987; Ydreborg, 1990). Eight questions were asked about lower back problems and correspondingly eight questions about shoulder and neck problems. The standardized form contains a number of questions concerning work experience and lifestyle as well as yes-no questions about pain and the time and length of musculoskeletal problems. The intensity of the problems is mirrored by change of work and doctors’ visits. Both groups also answered non-standardized forms about their professional education at the end of their training and at follow-up. Fifteen questions covered the students’ opinions about their education on visual analogue scales. Although the value of subjective ratings made on VAS-scales may be questionable, they do appear to provide reliable ratings which mirror participants opinions (Huskisson, 1983). Six questions concerned the psycho-social environment during education and the answers were on a four-grade scale. The experimental group also answered questions about the ergonomy educational package. At follow-up, two open-ended questions asked for what there had been too much or too little of during their 2 years of education.
Observations
Five age-matched nurses from each group were observed during work on the ward. The observed work-tasks were standardized in order to be comparable. Everyone observed accomplished the same work-tasks. The observations were carried out by an independent blind observer 4 months after the nurses’ final examination. The method of direct registration of work movements and work strain with a portable PC has been developed at the Institution for Industrial Ergonomy at Linkoping, Sweden, and reported at the 11th Congress of the International Ergonomic Association. The method has been shown to have a good test-retest reliability (Fransson et al., 1991). The sampling is continuous and work positions, movements and the handling of objects are directly registered during observation. A sample of variables had to be chosen for observation. Work-tasks chosen for the observation were distributing lunch, making a bed, taking a venous blood-test, dressing a wound on a foot and transferring a patient who needed some help from bed to chair and vice versa. These work-tasks were judged to be typical situations. Within each observation period the time in a static position was registered for neck, arms and trunk. Lifts were registered with the weight, which way it was moved and the body position during the lift.
Statistical analysis
The questionnaire data were analysed in the following way. Within-group differences were tested for significance with the paired t-test for correlated continuous measurement, and with McNemar’s test for dichotomous measurement. The significance of betweengroup differences was assessed with t-tests for independent continuous measurements and with chi-square tests for nominal and ordinal data. The observations in the work situation, concerning time in unfavourable positions and lifting technique were not tested for statistical significance due to the small group sizes.
A.-L. HELLSING
504
Evaluation
et al.
of the nursing program
At the time of the examination. Of the 15 questions about education, with answers on visual analogue scales, three showed significant differences between the groups. The endpoints on the visual analogue scales were, “not at all” and “very much”. The questions were “To what extent did you find that the education increased between back pain and psycho-social work environment?”
Mean mm Variance P = 0.000
C-group
E-group
46.64 26
13.94 19
“To what extent did you find that the education between back pain and work technique?’
increased
C-group
E-group
52.76 23.5
68.40 22.3
your knowledge
about
the relationship
your knowledge
about
the relationship
.___. Mean mm Variance P = 0.000 “To what extent has the education back and neck pain?’
increased
your ability to identify work factors
C-group Mean mm Variance P = 0.000
of importance
for
E-group
52.3 23.7
19.9 15.0
There were no significant differences between the groups on the remaining questions like “To what extent have you been able to practise your knowledge of stress during the education?’ (P = 0.099-0.71).
of work technique
and handling
There were no significant differences between the groups on questions concerning situations outside the workplace, i.e. “How important do you find that your ability work satisfaction?’ (P = 0.5).
to relax and handle
stress outside
work is for your
Six questions with answers on a four-grade scale all showed significant differences between the groups. These questions concerned the content in the different parts of the education and the psycho-social climate during the 2 years. One of these questions was the more global: Do you find that your professional
training
corresponds
to your expectations?
C-group E-group % % ________Not at all To a small To a fairly To a high P = 0.041
extent high extent extent (two-tailed f-test)
32 66 3
17 61 22
At the time of examination the experimental group was also asked
ERGONOMIC “Has the extra education
EDUCATION
been a great burden
FOR NURSING
505
STUDIES
to you?’
Fifteen students answered “not at all” and five answered “to a slight degree”, none answered “yes, to some extent” or “yes, to a high degree”. The open comment was: “On the contrary, this ought to be part of the normal education”. At ,follow-up, 1 year later. Both groups were asked two questions, also with answers on visual analogue scales. The endpoints were “not at all what I have been needing” and “exactly what I have been needing”. These questions did not show significant differences between the groups. “Did you find that your professional
training
contained
C-group Mean mm Variance P = 0.167
Mean mm Variance P = 0.054
“Which
E-group 61.2 13.5
58.2 34.6
“How do you find that your training met your needs?”
The open questions answers.
what you have been needing?’
were analysed
parts of the education
in work techniques,
leadership
C-group
E-group
59.13 33.34
72.95 15.13
after classification
and work organization
has
of the
could be reduced?’
One-third of both groups expressed that there had been too much made of research methods and report writing. The groups differed, however, on the question about what there had been “too little” of. Two-thirds of the control group vs one-third of the experiment group answered that there had been too little of the basic subjects like anatomy and learning about diseases. One conclusion would be that the extra education in ergonomy had not been administered at the expense of other basic subjects. Musculoskeletal problems The total incidence of neck-shoulder and back problems as seen in Table 1 at pre-test was similar to normative data (Biering-Sorensen, 1989). The first assessment reflects the situation at the start of the education, the third and fourth the situation at graduation and follow-up, respectively. Neck problems were more stable than lower back problems for both groups (Fig. 1). Lower back pain decreased during the 2 years of the study and then returned to pre-test levels for both groups. Shoulder pain decreased during the study period, particularly for the control group. The decrease in lower back pain frequency within the control group during the study period is significant (P = 0.0352, McNemar’s test). No other differences between groups were significant. Can new problems be prevented? Persons without problems at the start but with back or neck pain at follow-up could be looked upon as “new” problems. In the control group
506
A.-L. HELLSING
Musculo-skeletal over three years
100
Percent with
neck
problems observation
et al
in the two groups period.
pain m 0
80
Experimentgroup Co”rrolgroup
60
Jan 1988 100
Jan 1989
Percent wrrh shoulder
Jan 1990
Jan 1991
Jan 1990
Jan 1991
Jan 1990
Jan 1991
pain
80 60
Jan 1988
Jan 1989
100 Percent with low back
pain
80 60 40 ]mmgj
20 0 Jan 1988
Jan 1989
Fig. 1. Musculoskeletal problems in the two groups over a 3-year observation period.
there were six persons with new neck problems, compared to one in the experimental group. There were two persons with new lower back problems in the control group and two in the experimental group. Seven persons changed from having back pain to “no pain” in the control group and three changed in the same direction in the experimental group. No obvious short-term effect of the education on musculoskeletal problems could be shown. Age dependence. As we could not influence admission to the education there was unfortunately an age difference between the two groups (Table 1). The musculoskeletal problems have been analysed for the effects of age. Neck and shoulder problems did not show a significant correlation to age according to a chi-square test. The occurrence of neck problems during the last year was not significantly correlated to age in either group (C-group, P = 0.60; E-group, P = 0.21). Lower back pain was, on the whole, not correlated to age, but within the experimental group the older participants showed a higher frequency of pain. Analysing the effect of age on changes of back and neck problems is not possible because of the small groups. Those seven persons in the C-group who stated improvement of their
ERGONOMIC
back pain were all under years of age. Observation
EDUCATION
FOR NURSING
and those three who improved
507
STUDIES
in the E-group
were all over 30
results
Figures 2 and 3 graphically depict the in vivo observations of biomechanics. It may be seen (Fig. 2) that during the work-task, serving lunch/making bed the experimental group worked in several respects what we would consider better. The figure shows the number of lifts for each group. The control group without the extra education here shows a great number of more lifts with bent trunk (over 20”) as with long leaver arm and also the combination of flexed and rotated trunk and long leaver arm. “Correct” here means not rotated and the trunk flexed not over 20° and work within underarm distance. For the work-task, patient transfer (Fig. 3) the experimental group used less trunk tlexion and instead a little more knee-flexion expressed as part of the worked time. The control group had a three-fold longer time spent with the trunk flexed more than 20”. For the work-tasks, taking blood sample/dressing a wound, the experimental group worked with less flexed and rotated necks and less flexed trunks expressed as part of the worked time.
Observation of a sample from each group during care/serving food, making bed
E-group
n=5
C-group
PI=5
0 Correct
Rotated
Flexed forward
Long
Combination
1.TV.S arm
Type of lift Fig. 2. Observation
of a sample from each group during
care/serving
food and making
bed
Discussion and conclusion
The results show that this ergonomy package was well received by the students. The extra hours could fit into the normal schedule and their content was well adapted to other subjects and practice periods.
508
A.-L. HELLSING
Patient
transfer
from
et al.
bed to chair
n
E-group
n=5
•j
C-group
n=s
and vice
versa
20 r-
0
Neck flexed
Neck
rotated Body
Fig. 3. Patient
transfer
Trunk flexed
Trunk rotated
KIlPXS flexed
position
from bed to chair and vice versa.
From the assessment questions it could be concluded that the study group was more content with their education and that the extra training was not carried out at the expense of any of the other basic subjects. Although the value of subjective ratings made on VAS-scales may be questionable, they do appear to provide reliable ratings which mirror participants’ opinions. The visual analogue scale mirrors the person’s own opinion and cannot of course be regarded as a comparable objective measure on an interval scale. The potential practical value of the education was shown in the observed differences in work technique. The study group knew how to work “better” from an ergonomic point of view. One criticism that might be raised is that participants who were observed were aware of the observation. However, this condition was the same for both groups. In spite of the small groups observed, differences were recorded. This suggests that the size of the difference was large, but the generality of the findings is uncertain. The method of practical observation worked well though was time consuming. The effect of the education on reported musculoskeletal pain was not obvious during the follow-up year. However, very obvious was the trend of reduction of lower back and shoulder problems for both groups during the 2 years of study instead of hospital work. Another question relates to the overall problem of handling changes. The experimental group with new knowledge returned to the normal situation. They experienced big problems in implementing changes which they saw as very important. The nurse has a key role concerning the work environment in the hospital and needs broad knowledge and understanding, but also needs the authority and resources to execute the necessary changes. In order to keep skilled nurses at work it may be necessary to allow nurses’ ideas to have an actual impact on the organization. One of the aims of this project was to convey the idea that ergonomic education for hospital personnel is not complete with just learning how to transfer patients with minimal effort. The education had to address problem areas which often hinder the use of correct work technique: (i) stress management; (ii) how to solve administrative and organizational problems which cause tired and irritable persons to perform unguided lifting; (iii) how to learn not to lift when the patient can help themself and may be better off when they do;
ERGONOMIC
EDUCATION
FOR NURSING STUDIES
509
and (iv) how to learn to feel and accept your limits, and your value as a person worth taking care of. The long-term effect on sick-absence and turn-over remains to be shown in, for example, a 5-year follow-up. The main idea of the project-that ergonomy education should be broadened and contain all the elements presented here-makes it difficult to study the effects in the long run. As a result of the project the school with the control group has. changed their education. The results from the study must be looked at with an awareness that the students were not randomly selected. This would have been ideal, but was not possible. Where this could be possible is in the case of parallel classes in the same school, given that they are enough apart to have different programmes. The results warrant future large-scale investigations with (i) random groups and matched ages; (ii) larger groups for observation; and (iii) a follow-up over a long period. Physical training in Sweden was excluded from the nursing training when this was changed into a university degree. Daily physical training in the form of any kind of sports and gymnastics as part of the programme was not possible but ought to be part of the normal education. With the growing numbers of musculoskeletal problems, physical training should be part of both the basic education and the professional work, as it is for military officers, policemen and firemen. Just as in sports, warming up should be a routine carried out before hard work; pause gymnastics is also a good routine. Ac,kno,~,le~9emmr.~~~This project was supported by the Swedish Work Environment Fund. We are also grateful to Anna Magi, physiotherapist and psychologist, who taught body awareness and the physiotherapists, Inga Olsson and Isabel Landstrom. who taught physical training. Birgitta Beckman has, together with Birgitta Andershed and Christina Bergman, been a teacher in nursing. Ing-Liss Bryngelsson and Cheryl Suneborn accomplished the data analysis and we are grateful to Kerstin Akerstedt for the typing.
References Biering-Sorensen, F., Thomsen, C. E. and Hilden, J. (1989). Risk indicators for low back trouble. Stand. J. Rehuh. Med. 21, 151-157. ChatIin, D. B.. Herrin, G. D. and Keyserling. W. M. (1978). Preemployment strength testing. J. Oct. Meal. 20, 403-408. Dehlin, O., Hedenrud. B. and Horal, J. (1976). Back symptoms in nursing aides in a geriatric hospital. Srand. J. Rehah. Med. 8, 47--53. Donchin, M., Woolf, 0.. Kaplan, L. et (11.(1990). Secondary Prevention of low back pain. A clinical trial. Spine 15, 1317~1320. Estryn-Behar, M.. Kaminski, M., Peigne, E. et al. (1990). Strenuous working conditions and musculo-skeletal disorders among female hospital workers. Inr. Arch. Oct. Environ. Hlth 62,47-57. Fransson C., Gloria, R., Kilbom, A. et ul. (I 991). Presentation and evaluation of a portable ergonomic observation method. In Proceedings of the 1I th Congress qfthe International Ergonomics Asrociation, Paris 1991, pp. 242 244. Taylor and Francis. Gagnon. M., Akre, F., Chehade, A. cr (11.(1987). Mechanical work and energy transfers while turning patients in bed. Ergonomics 30, 1515-1530. Haig, A. J.. Linton, P., McIntosh, M. et ~1. (1990). Aggressive early medical management by a specialist in physical medicine and rehabilitation: effect on lost time due to injuries in hospital employees. J. Oct. Metl. 32, 241 244. Huskisson, B. C. (1983). Visual analogue scales. In Pain Measurement and Assessment (Melzack. R., Ed.). pp. 33 37. Raven Press. New York. Jensen, R. C. (1990). Prevention of back injul;ies among nursing staff. In Essentials qf Modern Hospi~ul Safe/,, (Charney, W. and Schirmer, J., Eds), pp. 237-258. Lewis, Publishers, MI. K umar, S. (1990). Cumulative load as a risk factor for back pain. Spine 15, 13 1I- I3 16. Kuorinka, B., Jonsson, B., Kilbom, A. er al. (1987). Standardised Nordic questionnaires for the analysis of musculoskeletal symptoms. Appl. Ergonom. 18, 233 237.
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et al.
Linton, S. J. (1990). Risk factors for neck and back pain in a working population in Sweden. Work Stress 4,4149. Lortie, M. (1987). Structural analysis of occupational accidents affecting orderlies in a geriatric hospital. J. Oct. Med. 29,437444. Stappaerts, K. H. (1989). Low back pain and related sick leave in nurses. Physiother. Practice 5, 1933200. Stubbs, D. A., Buckle, P. W., Hudson, M. P. et al. (1983). Back pain in the nursing profession. Epidemiology Ergonomics 26, 755-765. and pilot methodology. Videman, T., Kurminen, T., Tola, S. et al. (1984). Low back pain in nurses and some loading factors of work. Spine 9,40&404. Wood, D. J. (1987). Design and evaluation of a back injury prevention program within a geriatric hospital. Spine 12,77-82. Ydreborg, B. (1990). Questionnaire-based database on occupation and health status. Information Services and Use 10,47-5 1. Elsevier, Amsterdam. (Received 27 May 1992;
infinal form 10 November 1992; accepted for publication 10 November 1992)
1993 0
CW!O-7489/93 $6.@0+0.00 1993 Pergamon Press Ltd
Ergonomic education for nursing students ANNA-LISA HELLSING, R.P.T.” STEVEN J. LINTON, Ph.D. Department of Occupational Medicine. &ebro Regional Hospital, S-70185 tirebro, Sweden
BIRGITTA ANDERSHED, CHRISTINA BERGMAN, College
R.N. R.N.
qf Nursing iirebro, Sweden
MARGARETA
LIEW, R.P.T.
Departmenr of Industrial Ergonomy. Linkiiping University. Sweden
Abstract--An educational package of common ergonomic training as well as behavioural training was implemented in nursing education. The teaching methods also had the aim of increasing students’ awareness of the importance of total work environment for the prevention of back injuries. The experimental group was, on the whole, more pleased with their education than the control group. The experimental group judged their ability to analyse the work environment higher than the control group did. Observations in some practical worktasks showed that students from the experimental group worked in physically more favourable positions with less strain on the body.
Introduction
One of the biggest environmental
risks facing nurses is work-related back pain. Although
*Author to whom correspondence should be addressed.
499
500
A.-L. HELLSING
et al.
nursing experience may enable reduction of other risks such as work stresses, back pain normally increases in frequency with age. Even if we cannot expect to completely prevent back pain, the high occupational risk for nurses demands that interventions to diminish the risk as well as the consequences of injury be taken. Caring for sick people still means frequent and often heavy lifting (Gagnon et al., 1987). Occupational back pain and accidents related to lifting during care constitute a major risk for sick-listing among nursing personnel (Jensen, 1990; The Swedish National Board of Occupational Safety and Health). Learning correct use of body mechanics and lift technique is one main point. Another is to overcome obstacles that may hinder the use of correct techniques. The aim of this project was therefore to design, implement and evaluate an educational module within a nursing programme concerning the prevention of back and neck pain among nurses. Back pain in nursing Back and neck pain are common among the general population but increase when worktasks include heavy lifting or awkward work positions (Chaffin, 1978; Kumar, 1990). Those women with work consisting of frequent heavy lifting have twice the frequency of back pain compared with those with similar work but with less heavy lifting (Estryn-Behar et al., 1990). The overall prevalence of back pain is often reported to be 60-70% (BieringSorensen, 1989). The l-year prevalence of around 50% for nurses and nursing aides points to frequent relapses (Dehlin et al., 1976; Stappaerts, 1989). Stubbs (1983) found that 43% of those with back pain during the last year had had seven or more relapses. Another study of nursing aides showed the maximum frequency of back pain at the surprisingly low age of 20-24 years (Videman et al., 1984). These statistics suggest that nurses suffer their first back “injury” shortly after leaving nursing school and that once “injured” they will suffer periodic problems. Accidents causing back pain According to official Swedish statistics (The Swedish National Board of Occupational Safety and Health), nursing personnel is the professional group with the highest number of occupational accidents among women. Among women, over-exertion is the probable reason for one-third of the accidents. Over-exertion of the musculoskeletal system also results in a comparably longer sick leave than for other accidents: 45 days for women (1987) as compared to an average of 32 days for all work-related accidents. Aetiology for pain and accidents Lifts. The heavy or unexpected lift in an incorrect position is a common reason for back pain from occupational accidents. This is an excellent description of many of the situations that apparently occur in health-care. Accidents within a geriatric clinic for instance, were analysed by Lortie (1987) and it was shown that most accidents were related to patient transfer. These accidents caused longer sick leave periods than other accidents, particularly if the sick-listing was delayed by at least 3 days after the accident. Organization. Stress and work organization have recently been highlighted as key factors for successfully reducing the risk of injuries to the musculoskeletal system (Linton, 1990). Unrealistic expectations or unsafe situations often under time restraints are common in hospitals.
ERGONOMIC
EDUCATION
FOR NURSING
STUDIES
SO1
Patient lifting or transfer is apparently integrally connected to routines and the social climate at work. The nursing profession also involves a complex psycho-social environment where nurses must cope with high levels of physical (e.g. lifts), psychological (life or death) and social (work conflicts, patients, family demands) stress which often is unpredictable in terms of when, where and how intense the situation will be. All occupational accidents will not be preventable. The person affected needs prompt and active attention to recover as soon as possible and thereby reduce time off work (Donchin et al., 1990; Haig et al., 1990). Nurses’ ergonomic education
Licensed practical nurses receive a nursing degree after 2 years of additional nursing school education. The 2 years contain three theoretical blocks, which increase in specialization. Between and within the theoretical courses the students have supervised practice in different areas. Within these 2 years, 5 hours are devoted to nursing ergonomy. Although the exact content varies from school to school, this usually means anatomy, physiology and biomechanics as bases for understanding practical applications, e.g. patient transfers. Actual practice of transfers and lifting is, however, not included in this time. The role of the nurse in health-care is changing. Nurses today have a rapidly developing supervisory role and therefore need both knowledge and understanding to meet the usual demands of providing high-quality health-care as well as new demands as supervisory personnel. Wood (1987) has shown, for example, that supervisors’ active interest is of great importance in returning a person to work after an attack of back pain. In fact, maintaining positive contact had a greater effect than a back-school. Unfortunately, these facts do not seem to be highlighted during nursing education. Often the tradition of being a servant is a heavy burden on the nursing profession. Ideas about the project
If education is to help prevent occupational back pain the training ought to be introduced as early as possible during the basic professional training so that proper work techniques are developed. At the same time, work technique and organization do not seem to be given high priority among nursing students. Work technique, e.g. lifting and transfer, may not yet be looked upon as an important factor that can result in serious injury. Consequently, one aim of the study was to raise the students’ awareness of the importance of the total work environment for musculoskeletal problems. Another goal was to teach work routines and techniques so that the students would actually apply them at work. The basic assumption was that if students became more aware of the problem and learned as well as applied proper work routines and techniques, then occupational back and neck pain would be reduced. This paper reports on the development of an ergonomy education package for nursing students and the short-term effects of this education in terms of attitudes and behaviours. Methods
Overview of the design
Two nursing schools within the same geographical area participated, with one serving as the normal educational programme and the other as an experimental group where the ergonomy package was administered.
A.-L. HELLSING et al.
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Procedure
Students in both schools completed an assessment at the start, half-way through and at the completion of their education and as a l-year follow-up. The teachers were free to implement their ideas about learning principles and also to add to this extra broad ergonomic education. Table 1 Subjects Number of persons Average age Average no of years of hospital work Experienced neck pain previous year Experienced back pain previous year
E-group
c-group
19 38 9 45% 55%
33 25 5 34% 59%
Control group
Students in the control group received the usual curriculum. The only change induced by the study was the assessment procedure. Extra education group
The extra education for the experimental group was integrated into the 2-year programme with an average of 2 hours of ergonomy per week. During the first semester (10 weeks) the extra education started with the theory and the practice of relaxation. Different methods were practised at rest, sitting and lying. Body awareness and basic correct biomechanics were practised both individually and in groups. Within the second semester the extra education started with a 2-day workshop where students were introduced to the ideas of physical and psychological training and also practised training. Subsequently the “traditional” ergonomic education started with practice in patient transferring techniques. The students also had some lessons and practice in pause gymnastics. The extra education in the third semester (40 weeks) contained lectures and discussions about pain-perception and physiology and how pain can be modulated by culture, expectations, social situations and psychological state. The importance of the psycho-social work environment was enlarged on with lectures, group exercises, discussions and homework. Models for coping with stress and pain were discussed and practised. The supervisors’ role in preventing injuries in addition to leading personnel was emphasized. The students wrote suggestions for preventive programmes towards musculoskeletal problems which they analysed during the following practice period. An intense 3-day course in technique for patient transfers was also conducted. At the end of their education the students also had teaching experience in instructing other personnel on the ward and the younger students. Assessment
Questionnaires
Both groups were asked to complete questionnaires. The first was a widely used standardized form from the Nordic Council of Ministers concerning musculoskeletal problems
ERGONOMIC
EDUCATION
FOR NURSING
STUDIES
so3
which they answered four times over the 3 years. The questionnaires have been tested for reliability and validity and shown to be acceptable (Kuorinka et al., 1987; Ydreborg, 1990). Eight questions were asked about lower back problems and correspondingly eight questions about shoulder and neck problems. The standardized form contains a number of questions concerning work experience and lifestyle as well as yes-no questions about pain and the time and length of musculoskeletal problems. The intensity of the problems is mirrored by change of work and doctors’ visits. Both groups also answered non-standardized forms about their professional education at the end of their training and at follow-up. Fifteen questions covered the students’ opinions about their education on visual analogue scales. Although the value of subjective ratings made on VAS-scales may be questionable, they do appear to provide reliable ratings which mirror participants opinions (Huskisson, 1983). Six questions concerned the psycho-social environment during education and the answers were on a four-grade scale. The experimental group also answered questions about the ergonomy educational package. At follow-up, two open-ended questions asked for what there had been too much or too little of during their 2 years of education.
Observations
Five age-matched nurses from each group were observed during work on the ward. The observed work-tasks were standardized in order to be comparable. Everyone observed accomplished the same work-tasks. The observations were carried out by an independent blind observer 4 months after the nurses’ final examination. The method of direct registration of work movements and work strain with a portable PC has been developed at the Institution for Industrial Ergonomy at Linkoping, Sweden, and reported at the 11th Congress of the International Ergonomic Association. The method has been shown to have a good test-retest reliability (Fransson et al., 1991). The sampling is continuous and work positions, movements and the handling of objects are directly registered during observation. A sample of variables had to be chosen for observation. Work-tasks chosen for the observation were distributing lunch, making a bed, taking a venous blood-test, dressing a wound on a foot and transferring a patient who needed some help from bed to chair and vice versa. These work-tasks were judged to be typical situations. Within each observation period the time in a static position was registered for neck, arms and trunk. Lifts were registered with the weight, which way it was moved and the body position during the lift.
Statistical analysis
The questionnaire data were analysed in the following way. Within-group differences were tested for significance with the paired t-test for correlated continuous measurement, and with McNemar’s test for dichotomous measurement. The significance of betweengroup differences was assessed with t-tests for independent continuous measurements and with chi-square tests for nominal and ordinal data. The observations in the work situation, concerning time in unfavourable positions and lifting technique were not tested for statistical significance due to the small group sizes.
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Evaluation
et al.
of the nursing program
At the time of the examination. Of the 15 questions about education, with answers on visual analogue scales, three showed significant differences between the groups. The endpoints on the visual analogue scales were, “not at all” and “very much”. The questions were “To what extent did you find that the education increased between back pain and psycho-social work environment?”
Mean mm Variance P = 0.000
C-group
E-group
46.64 26
13.94 19
“To what extent did you find that the education between back pain and work technique?’
increased
C-group
E-group
52.76 23.5
68.40 22.3
your knowledge
about
the relationship
your knowledge
about
the relationship
.___. Mean mm Variance P = 0.000 “To what extent has the education back and neck pain?’
increased
your ability to identify work factors
C-group Mean mm Variance P = 0.000
of importance
for
E-group
52.3 23.7
19.9 15.0
There were no significant differences between the groups on the remaining questions like “To what extent have you been able to practise your knowledge of stress during the education?’ (P = 0.099-0.71).
of work technique
and handling
There were no significant differences between the groups on questions concerning situations outside the workplace, i.e. “How important do you find that your ability work satisfaction?’ (P = 0.5).
to relax and handle
stress outside
work is for your
Six questions with answers on a four-grade scale all showed significant differences between the groups. These questions concerned the content in the different parts of the education and the psycho-social climate during the 2 years. One of these questions was the more global: Do you find that your professional
training
corresponds
to your expectations?
C-group E-group % % ________Not at all To a small To a fairly To a high P = 0.041
extent high extent extent (two-tailed f-test)
32 66 3
17 61 22
At the time of examination the experimental group was also asked
ERGONOMIC “Has the extra education
EDUCATION
been a great burden
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STUDIES
to you?’
Fifteen students answered “not at all” and five answered “to a slight degree”, none answered “yes, to some extent” or “yes, to a high degree”. The open comment was: “On the contrary, this ought to be part of the normal education”. At ,follow-up, 1 year later. Both groups were asked two questions, also with answers on visual analogue scales. The endpoints were “not at all what I have been needing” and “exactly what I have been needing”. These questions did not show significant differences between the groups. “Did you find that your professional
training
contained
C-group Mean mm Variance P = 0.167
Mean mm Variance P = 0.054
“Which
E-group 61.2 13.5
58.2 34.6
“How do you find that your training met your needs?”
The open questions answers.
what you have been needing?’
were analysed
parts of the education
in work techniques,
leadership
C-group
E-group
59.13 33.34
72.95 15.13
after classification
and work organization
has
of the
could be reduced?’
One-third of both groups expressed that there had been too much made of research methods and report writing. The groups differed, however, on the question about what there had been “too little” of. Two-thirds of the control group vs one-third of the experiment group answered that there had been too little of the basic subjects like anatomy and learning about diseases. One conclusion would be that the extra education in ergonomy had not been administered at the expense of other basic subjects. Musculoskeletal problems The total incidence of neck-shoulder and back problems as seen in Table 1 at pre-test was similar to normative data (Biering-Sorensen, 1989). The first assessment reflects the situation at the start of the education, the third and fourth the situation at graduation and follow-up, respectively. Neck problems were more stable than lower back problems for both groups (Fig. 1). Lower back pain decreased during the 2 years of the study and then returned to pre-test levels for both groups. Shoulder pain decreased during the study period, particularly for the control group. The decrease in lower back pain frequency within the control group during the study period is significant (P = 0.0352, McNemar’s test). No other differences between groups were significant. Can new problems be prevented? Persons without problems at the start but with back or neck pain at follow-up could be looked upon as “new” problems. In the control group
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Musculo-skeletal over three years
100
Percent with
neck
problems observation
et al
in the two groups period.
pain m 0
80
Experimentgroup Co”rrolgroup
60
Jan 1988 100
Jan 1989
Percent wrrh shoulder
Jan 1990
Jan 1991
Jan 1990
Jan 1991
Jan 1990
Jan 1991
pain
80 60
Jan 1988
Jan 1989
100 Percent with low back
pain
80 60 40 ]mmgj
20 0 Jan 1988
Jan 1989
Fig. 1. Musculoskeletal problems in the two groups over a 3-year observation period.
there were six persons with new neck problems, compared to one in the experimental group. There were two persons with new lower back problems in the control group and two in the experimental group. Seven persons changed from having back pain to “no pain” in the control group and three changed in the same direction in the experimental group. No obvious short-term effect of the education on musculoskeletal problems could be shown. Age dependence. As we could not influence admission to the education there was unfortunately an age difference between the two groups (Table 1). The musculoskeletal problems have been analysed for the effects of age. Neck and shoulder problems did not show a significant correlation to age according to a chi-square test. The occurrence of neck problems during the last year was not significantly correlated to age in either group (C-group, P = 0.60; E-group, P = 0.21). Lower back pain was, on the whole, not correlated to age, but within the experimental group the older participants showed a higher frequency of pain. Analysing the effect of age on changes of back and neck problems is not possible because of the small groups. Those seven persons in the C-group who stated improvement of their
ERGONOMIC
back pain were all under years of age. Observation
EDUCATION
FOR NURSING
and those three who improved
507
STUDIES
in the E-group
were all over 30
results
Figures 2 and 3 graphically depict the in vivo observations of biomechanics. It may be seen (Fig. 2) that during the work-task, serving lunch/making bed the experimental group worked in several respects what we would consider better. The figure shows the number of lifts for each group. The control group without the extra education here shows a great number of more lifts with bent trunk (over 20”) as with long leaver arm and also the combination of flexed and rotated trunk and long leaver arm. “Correct” here means not rotated and the trunk flexed not over 20° and work within underarm distance. For the work-task, patient transfer (Fig. 3) the experimental group used less trunk tlexion and instead a little more knee-flexion expressed as part of the worked time. The control group had a three-fold longer time spent with the trunk flexed more than 20”. For the work-tasks, taking blood sample/dressing a wound, the experimental group worked with less flexed and rotated necks and less flexed trunks expressed as part of the worked time.
Observation of a sample from each group during care/serving food, making bed
E-group
n=5
C-group
PI=5
0 Correct
Rotated
Flexed forward
Long
Combination
1.TV.S arm
Type of lift Fig. 2. Observation
of a sample from each group during
care/serving
food and making
bed
Discussion and conclusion
The results show that this ergonomy package was well received by the students. The extra hours could fit into the normal schedule and their content was well adapted to other subjects and practice periods.
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Patient
transfer
from
et al.
bed to chair
n
E-group
n=5
•j
C-group
n=s
and vice
versa
20 r-
0
Neck flexed
Neck
rotated Body
Fig. 3. Patient
transfer
Trunk flexed
Trunk rotated
KIlPXS flexed
position
from bed to chair and vice versa.
From the assessment questions it could be concluded that the study group was more content with their education and that the extra training was not carried out at the expense of any of the other basic subjects. Although the value of subjective ratings made on VAS-scales may be questionable, they do appear to provide reliable ratings which mirror participants’ opinions. The visual analogue scale mirrors the person’s own opinion and cannot of course be regarded as a comparable objective measure on an interval scale. The potential practical value of the education was shown in the observed differences in work technique. The study group knew how to work “better” from an ergonomic point of view. One criticism that might be raised is that participants who were observed were aware of the observation. However, this condition was the same for both groups. In spite of the small groups observed, differences were recorded. This suggests that the size of the difference was large, but the generality of the findings is uncertain. The method of practical observation worked well though was time consuming. The effect of the education on reported musculoskeletal pain was not obvious during the follow-up year. However, very obvious was the trend of reduction of lower back and shoulder problems for both groups during the 2 years of study instead of hospital work. Another question relates to the overall problem of handling changes. The experimental group with new knowledge returned to the normal situation. They experienced big problems in implementing changes which they saw as very important. The nurse has a key role concerning the work environment in the hospital and needs broad knowledge and understanding, but also needs the authority and resources to execute the necessary changes. In order to keep skilled nurses at work it may be necessary to allow nurses’ ideas to have an actual impact on the organization. One of the aims of this project was to convey the idea that ergonomic education for hospital personnel is not complete with just learning how to transfer patients with minimal effort. The education had to address problem areas which often hinder the use of correct work technique: (i) stress management; (ii) how to solve administrative and organizational problems which cause tired and irritable persons to perform unguided lifting; (iii) how to learn not to lift when the patient can help themself and may be better off when they do;
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and (iv) how to learn to feel and accept your limits, and your value as a person worth taking care of. The long-term effect on sick-absence and turn-over remains to be shown in, for example, a 5-year follow-up. The main idea of the project-that ergonomy education should be broadened and contain all the elements presented here-makes it difficult to study the effects in the long run. As a result of the project the school with the control group has. changed their education. The results from the study must be looked at with an awareness that the students were not randomly selected. This would have been ideal, but was not possible. Where this could be possible is in the case of parallel classes in the same school, given that they are enough apart to have different programmes. The results warrant future large-scale investigations with (i) random groups and matched ages; (ii) larger groups for observation; and (iii) a follow-up over a long period. Physical training in Sweden was excluded from the nursing training when this was changed into a university degree. Daily physical training in the form of any kind of sports and gymnastics as part of the programme was not possible but ought to be part of the normal education. With the growing numbers of musculoskeletal problems, physical training should be part of both the basic education and the professional work, as it is for military officers, policemen and firemen. Just as in sports, warming up should be a routine carried out before hard work; pause gymnastics is also a good routine. Ac,kno,~,le~9emmr.~~~This project was supported by the Swedish Work Environment Fund. We are also grateful to Anna Magi, physiotherapist and psychologist, who taught body awareness and the physiotherapists, Inga Olsson and Isabel Landstrom. who taught physical training. Birgitta Beckman has, together with Birgitta Andershed and Christina Bergman, been a teacher in nursing. Ing-Liss Bryngelsson and Cheryl Suneborn accomplished the data analysis and we are grateful to Kerstin Akerstedt for the typing.
References Biering-Sorensen, F., Thomsen, C. E. and Hilden, J. (1989). Risk indicators for low back trouble. Stand. J. Rehuh. Med. 21, 151-157. ChatIin, D. B.. Herrin, G. D. and Keyserling. W. M. (1978). Preemployment strength testing. J. Oct. Meal. 20, 403-408. Dehlin, O., Hedenrud. B. and Horal, J. (1976). Back symptoms in nursing aides in a geriatric hospital. Srand. J. Rehah. Med. 8, 47--53. Donchin, M., Woolf, 0.. Kaplan, L. et (11.(1990). Secondary Prevention of low back pain. A clinical trial. Spine 15, 1317~1320. Estryn-Behar, M.. Kaminski, M., Peigne, E. et al. (1990). Strenuous working conditions and musculo-skeletal disorders among female hospital workers. Inr. Arch. Oct. Environ. Hlth 62,47-57. Fransson C., Gloria, R., Kilbom, A. et ul. (I 991). Presentation and evaluation of a portable ergonomic observation method. In Proceedings of the 1I th Congress qfthe International Ergonomics Asrociation, Paris 1991, pp. 242 244. Taylor and Francis. Gagnon. M., Akre, F., Chehade, A. cr (11.(1987). Mechanical work and energy transfers while turning patients in bed. Ergonomics 30, 1515-1530. Haig, A. J.. Linton, P., McIntosh, M. et ~1. (1990). Aggressive early medical management by a specialist in physical medicine and rehabilitation: effect on lost time due to injuries in hospital employees. J. Oct. Metl. 32, 241 244. Huskisson, B. C. (1983). Visual analogue scales. In Pain Measurement and Assessment (Melzack. R., Ed.). pp. 33 37. Raven Press. New York. Jensen, R. C. (1990). Prevention of back injul;ies among nursing staff. In Essentials qf Modern Hospi~ul Safe/,, (Charney, W. and Schirmer, J., Eds), pp. 237-258. Lewis, Publishers, MI. K umar, S. (1990). Cumulative load as a risk factor for back pain. Spine 15, 13 1I- I3 16. Kuorinka, B., Jonsson, B., Kilbom, A. er al. (1987). Standardised Nordic questionnaires for the analysis of musculoskeletal symptoms. Appl. Ergonom. 18, 233 237.
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Linton, S. J. (1990). Risk factors for neck and back pain in a working population in Sweden. Work Stress 4,4149. Lortie, M. (1987). Structural analysis of occupational accidents affecting orderlies in a geriatric hospital. J. Oct. Med. 29,437444. Stappaerts, K. H. (1989). Low back pain and related sick leave in nurses. Physiother. Practice 5, 1933200. Stubbs, D. A., Buckle, P. W., Hudson, M. P. et al. (1983). Back pain in the nursing profession. Epidemiology Ergonomics 26, 755-765. and pilot methodology. Videman, T., Kurminen, T., Tola, S. et al. (1984). Low back pain in nurses and some loading factors of work. Spine 9,40&404. Wood, D. J. (1987). Design and evaluation of a back injury prevention program within a geriatric hospital. Spine 12,77-82. Ydreborg, B. (1990). Questionnaire-based database on occupation and health status. Information Services and Use 10,47-5 1. Elsevier, Amsterdam. (Received 27 May 1992;
infinal form 10 November 1992; accepted for publication 10 November 1992)