Abstract
The aim of our study was to analyze home care workers’ movement patterns and back postures, relating them to risks while helping an ambulatory care recipient to and from the toilet in a homelike environment. We found that severe risks of unpredictable movements with exposed postures could explain many injuries. Because of high-risk injuries, we suggest decreasing the time when the care recipient stands and the home care worker helps with clothing and personal hygiene. We also suggest the development of support in front of the recipient to prevent her or him from falling forward.
Keywords
Identifying hazardous postures reveals potential solutions to safeguard both patients and health-care workers.
Helping an ambulatory care recipient to and from the toilet is a common task, and the environment in which this task is performed – the normal bathroom – is a frequently discussed problem area. One of the major findings of a recent survey about the reasons that elderly people move from an apartment or house to a nursing home revealed that persons with decreasing ability and increasing need for help, especially in the bathroom, were a common group (Larsson, 2007).
The home care sector is growing and is expected to continue to do so because of the increase in life spans of elderly people. This phenomenon is reported in many countries. Virtually all elderly people prefer to age and die in their own homes rather than in a nursing home (Mack, Salmoni, Viverais-Dressler, Porter, & Garg, 1997), which makes it important to design the future home environment to make it possible to provide care if necessary.
In this study, our aim was to analyze home care workers’ movement patterns and back postures. We wanted to learn more about potential injury risks, especially concerning musculoskeletal disorders for personnel when they are helping an ambulatory care recipient to and from the toilet in a homelike environment. The task was one that is typically performed in the beneficiary’s home, where the care worker is potentially exposed to an injury risk.
Background
Nursing is a dangerous job, carrying the risk of work-related musculoskeletal disorders and associated long-term sick leave. The most common disabilities are reported in the lower back, neck, and shoulders (Kim, Geiger-Brown, Trinkoff, & Muntaner, 2010; Kromark, Dulon, Beck, & Nienhaus, 2009). More than 50% of home care workers find their work physically demanding (Kim et al., 2010), and frequent patient transfers are described as one of the risk factors (Dellve, Lagerstrom, & Hagberg, 2003). The risk of injuries increases if the working posture includes both flexion and rotation of the back (Hoogendoorn et al., 2000), a posture often performed in home care work (Johansson, 1995).
To be able to reduce risks in home care work, one must know the details of how workers perform each task and where the risks occur. This research increases the possibilities to develop a better work environment and a better bathroom design to provide for opportunities for lifelong living in ordinary homes.
In this study, we used the International Standard 11226:2000 on ergonomics as reference for posture limitations. The standard defines a back inclination of <20° as “acceptable,” of 20° to 60° as “conditionally acceptable,” and of ≥60° as “critical.” Back inclination ≥60° is critical, independent of time. The time spent in a posture that includes back inclination should be limited, and it should never be combined with rotation or lateral flexion (ISO, 2000).
Test Design
For the recording of postures, we used the CUELA (computer-assisted recording and long-term analysis of musculoskeletal loads) measurement system (Ellegast, Hermanns, & Schiefer, 2009; Freitag, Ellegast, Dulon, & Nienhaus, 2007). Figure 1 shows the measurement system on one participant. We employed the ISO standard because it has been used with the CUELA system in earlier research (Freitag et al., 2007; Seidel et al., 2011). In addition, CUELA has been demonstrated to have good validity and reliability in field studies (Ellegast, 1998).
Participant with the CUELA (computer-assisted recording and long-term analysis of musculoskeletal loads) system.
The test was performed in a full-scale apartment/laboratory; the 30 participants were home care workers recruited from the Haninge Council’s home health care. Home care workers in this study are auxiliary nurses, who work with elderly and disabled care recipients in regular homes. Their mean stature was 168 cm (SD = 6) and mean weight was 70 kg (SD = 11). The mean age was 42 years (SD = 11); 4 of them were men and 26 were women. Their mean work experience was 9 years (SD = 7). None of the participants had musculoskeletal symptoms in the back, knees, or shoulders. All of the participants had participated in annual live practical training organized by their employer in the manual handling of care recipients as a normal procedure. That training was conducted with supervision by a physiotherapist.
The participants performed two cases involving aiding an ambulatory care recipient to and from the toilet. The scenario included help walking to the toilet, undressing (pants), being seated on the toilet, being raised from the toilet seat, wiping the bottom, and pulling up the pants.
The care recipient was an actor who performed rising and balance difficulties. The actor was used as a proxy to control such variables as different statures, weight, or abilities but, most important, to avoid exposing an older person to the potential risk of falling during the test. One variable was regarded as important to include in the test, as it poses different difficulties for performing the task: the use or nonuse of a four-wheeled walker in the home. Thus, Case 1 involved the care recipient walking with support of the walker, and Case 2 involved the care recipient walking only with support from the participant. The scenarios and cases are illustrated in Figure 2.
Description of scenarios and cases. CR = care recipient.
Participants were instructed to follow the care recipient to the toilet and help her or him with pants and hygiene as normally would be done. No other instructions were given about how the participant should perform the two cases. Figures 3 and 4 are photos from the different cases with the recipient actor and participant.
Participant and care recipient actor with a four-wheeled walker in the laboratory bathroom performing Case 1.
Participant and care recipient actor in the laboratory bathroom performing Case 2.
Every case was performed three times; the first one was considered a trial. The results presented in this article are the mean values of the second and third tests for each participant. The two cases were performed at two different times; because of scheduling problems, only 24 participants could participate in both Cases 1 and 2.
The bathroom was equipped as is a standard bathroom in Sweden, with the toilet hung on the wall, the distance from wall to the toilet front of 70 cm and toilet height at a standard 43 cm. The bathroom was 8 m2 in size, and the distance between the toilet and basin was 55 cm on the left side of the toilet.
Ethical approval was obtained from the local ethics research committee in Stockholm, and all participants provided written informed consent.
Observation of the movements was made with video recording. We used three cameras to make sure all angles of the participant were recorded, from the side, front, and above in the bathroom. The CUELA sensors were attached to the thoracic and lumbar spine as well as to the hip and knee joints. We recorded the following postures: inclination, lateral flexion and torsion of the back, and flexion in the hips and knee joints. All system components were attached to the participant, allowing him or her to move about freely.
At the start of the measurement, the participant assumed a standardized upright position with all body angles set at zero. The data collected from the CUELA were synchronized with the video recording through Widaan 2.75, software that was developed to make it possible to connect posture with the performed movement.
Our Analysis
Our focus in the analysis was to find risks related to posture and to describe in which part of the task they appear. We used the ISO limits for back inclination, 20° and 60°. A small rotation almost always occurred for all participants, and we chose to analyze rotation that exceeded 10°. In the Quick Exposure Check manual, rotation in the back should be noticed above 20° (David, Woods, Li, & Buckle, 2008). The limitation for rotations, according to the SIS standard, is always 0° when it occurs in combination with flexion, but it is built on experience from mostly observational studies, and it is difficult to notice a rotation <20° by simple observation.
The CUELA system is sensitive and shows every movement made by the participants. The participants performed rotation throughout all the test periods, but we chose to analyze only rotation that exceeded 10° as a compromise between observation recommendations and the SIS standard.
Helping someone to and from the toilet
The cases included more than one assignment (see Figure 2). In the first and last parts of the task, the participant walked with the care recipient to and from the toilet. The maximum back inclination in Case 1, when a walker was used, was 41°; in Case 2, without a walker, the inclination was 35°, in both cases performed by one participant. For all participants, the mean value of maximal back inclination was 24° (SD = 9) in Case 1 and 21° (SD = 6) in case 2.
Helping someone during visiting the toilet
After walking to the toilet, the care recipient needed help with pants and with sitting down on and rising up from the toilet. When a four-wheeled walker was used in Case 1, the participants chose to work from the side of the care recipient. One participant worked from both sides during the task. In Case 2, 22 participants worked from the side. In Case 2, one participant chose only to work from the front of the care recipient, and one participant alternated working from the side and from the front.
Dangerous work assignment?
The maximum back inclination for Case 1 was 98° performed by one person; in Case 2, the maximum back inclination was 74° performed by one person. The mean value for the participant’s maximum back inclination was 60° (SD = 11) in Case 1 and 57° (SD = 11) in Case 2. The mean value of minimum back inclination was 6° in both cases (Case 1, SD = 6; Case 2, SD = 5).
When we analyzed the data, we concluded that some postures in this task include dangerous back inclination. We found that postures including back inclination and rotation occurred during this task. Most of the time, but not always, the rotation and lateral flexion of the back occurred in combination with back inclination. These postures were related to the participant’s helping the care recipient with personal hygiene and pulling the pants up or down. In Tables 1 and 2, we describe the data from both cases and how many of the participants who assumed the respective postures during the different assignments were included in the task.
Number of Participants Who Assumed Different Work Postures in Specific Tasks in Case 1 (n = 30)
Note. CR = care recipient. Shaded areas represent 80% or more of the participants.
Number of Participants Who Assumed Different Work Postures in Specific Tasks in Case 2 (n = 24)
Note. CR = care recipient. Shaded areas represent 80% or more of the participants.
In our analysis, we realized that almost everyone performed a back inclination greater than 20° in all parts of helping a care recipient when visiting the toilet. We also concluded that helping someone pull the pants up or down is difficult without a back inclination greater than 40°. We noticed that an inclination greater than 60° was performed by, at most, one third of the participants. We did find that every participant performed a rotation and lateral flexion greater than 5° at least once during every step in the performed task but never the whole time.
Our aim has been to learn more about how to control and decrease the risk of overexertion injuries for home care workers in bathroom environments. Injury causations are complex, and several studies indicate that work in the bathroom is one of the problem areas in terms of overexertion injuries (Brulin, Winkvist, & Langendoen, 2000; Garg & Owen, 1992). We do not question those results; our study confirms that care givers assume postures during these cases that include back inclination, and it does occur repeatedly, sometimes even in combination with rotation and/or lateral flexion.
But in our analyses, we conclude that posture as an isolated part of the task is not enough to cause all the reported overexertion injuries. It can be assumed that anything unforeseen could happen as a part of the task. Injuries often occur in combination with “unpredictable” movements during assisting tasks among care workers, which could be a factor causing overexertion injuries (Engkvist, 2004; Garg & Owen, 1992). One could easily fall or lose one’s balance in this task. This scenario includes risk by assignment; the home care worker is there to help because the care recipient’s strength and balance are impaired for various reasons. The tasks include both exposed working postures for the home care worker and tasks affecting the care recipient’s balance.
There are two times when we interpret the risk for unpredictable movement as more obvious: first, when walking in and out of the bathroom, and second, when the care recipient is standing in front of the toilet and the care worker is assisting with pulling the pants down and back up and assisting with hygiene. In Figure 5, a fictional picture of how this unpredictable movement could happen is shown. The risk is the same when helping pulling up the pants. If the care recipient is falling forward and the home care worker tries to hinder the fall, the care worker would have to reach out in that direction, and because of the initial exposed posture, the risk of injury is increased.
Home care worker tries to hinder a fall forward.
Suggestions to Decrease the Risk of Injuries
The first potential time when injury risk occurs is when the participant follows the care recipient to the toilet, because the care recipient could fall. In this part of the task, the home care worker’s posture is mainly upright and flexible; the risk for injury could easily decrease if the home care worker were to use some kind of support for the care recipient. An example is a gait belt, which we suggest be used. The risk for falling also decreases if the care recipient uses an assistive device, as in our Case 1.
In developing bathrooms, effort should be made to include practical places for support, something to hold on to if the accident should occur. It could be a towel hanger placed in a strategic place; see Figure 6 for an example. The towel hanger is an alternative to a regular handrail, which is not always accepted among the elderly. The towel hanger, a common product, must be stable and securely mounted to the wall.
A towel hanger placed on the wall where the care recipient passes on the way into and out of the bathroom.
The second time when risks of an unpredictable movement occur is when the home care worker helps the care recipient with the pants, which might cause the recipient to move backward or forward. If the recipient falls backward, the toilet seat will hinder a fall, and we suggest that armrests be added to the toilet to increase security for the care recipient. To decrease the risk for injuries if the care recipient falls forward, we suggest the gait belt be used. We also think a support for use in front of the care recipient is needed. Such a support must be stable to aid the recipient when he or she stands up, but it must be flexible and easy to move when it is time to leave the bathroom. In Figure 7 we show one example.
A sketch of an example bathroom design, including handrail, support in front of care recipient, and a Bidette seat.
Conclusions
A bathroom needs to be large enough for the home care worker and recipient to move about safely; if one needs a four-wheeled walker for support, for example, one needs some extra space in the bathroom, particularly in front of the toilet. The bathroom should be provided with support in strategic places to decrease the risk of falling and causing injuries for both the care recipient and the home care worker. Based on our results, we suggest support on the way to the toilet and in front of the toilet. If the care recipient needs assistance in the bathroom, we suggest armrests on the side of the toilet. All bathrooms should be prepared for an easy mounting of supports next to the toilet that are strong enough to hold on to if someone loses his or her balance. This includes the basin and any wall-hung accessories.
To shorten the time for a home care worker to help with hygiene, the toilet seat bidet is a good solution and possibly appreciated by the care recipient as well (see Figure 7).
As the number of elderly people increases, the need for help in the bathroom environment is going to be more and more common. In this study, we have found that some of the exposure to injury risks could be decreased following the aforementioned suggestions. Because education in ergonomics for home care workers is difficult to accomplish, we suggest combining such education with video analyses of the worker’s own posture. Further testing and new assistive devices need to be developed. We believe this is important to make it possible for elderly persons to continue living at home.