Ergonomic principles in patient handling: Knowledge and practice of physiotherapists in Nigeria

Abstract

BACKGROUND:

Physiotherapists are advocates of workplace health and safety. Despite the high prevalence of work-related musculoskeletal disorders (WMSDs), there is limited knowledge of ergonomic principles have been successfully applied in the workplace by Nigerian physiotherapists.

OBJECTIVES:

This study evaluates the knowledge and practice of ergonomic principles in patient handling among physiotherapists in Nigeria.

METHOD:

A cross-sectional survey design was used to sample 360 physiotherapists practicing in Nigeria. Participants responded to a three-part structured questionnaire that had a reliability coefficient of 0.77. Data was analyzed using descriptive statistics and Chi-Square.

RESULTS:

The majority (95.9%) of the participants had good knowledge of the ergonomic principles in patient handling while only 48.6% reported practicing them. Poor practice was mainly due to a lack of patient handling equipment. There was no significant association between knowledge and practice of ergonomic principles among study participants. Specific areas of physiotherapy practice showed a significant association with ergonomic knowledge and practice. Years of physiotherapy practice and highest educational qualifications showed a significant association with the levels of practice and knowledge respectively.

CONCLUSION:

Physiotherapists in Nigeria reported a good level of knowledge of ergonomic principles, but a poor practice level. Perhaps this non-adherence contributed to the high prevalence of WMSDs among physiotherapists in Nigeria.

Keywords

Health care professionals manual handling musculoskeletal disorders workplace ergonomics

1 Introduction

One of the most significant ergonomic problems encountered in the workplace is work-related musculoskeletal disorders (WMSDs) [1, 2]. Physiotherapists and many healthcare professionals are predisposed to MSDs due to the physical nature of their job [3]. Currently, 40% of the world’s occupational and work-related health costs are attributed to musculoskeletal disorders [4, 5]. Interestingly, application of ergonomic principles has been successful in reducing the number of MSDs by over 50%, especially in professions that have high prevalence of WMSDs, such as the physiotherapy profession[6 –8].

Ergonomics play a role in fitting the job to the worker by providing the principles to accommodating the limitations and capacity of the worker [9]. Ultimately, good ergonomic principles aim to both reduce the job risk of injury and to enhance employee productivity. Therefore, mutual benefits for both the employers and the employees are realized [10]. There are workplace campaigns that incorporate good ergonomic practices among healthcare professionals who are at high risk of work-related musculoskeletal disorder [11]. These campaigns attempt to address the lack of awareness of good practice such as proper work posture which often exposes professionals to various health problems that reduces productivity and even unemployment in some extreme cases[6 , 12].

Previous studies have been done on awareness and perceived knowledge on the importance of ergonomics among healthcare professionals [13 –17]. Zakerian et al. [13] explored the relationship between knowledge of ergonomics and workplace conditions among nurses; and found that nurses who have a good knowledge of workplace ergonomic principles tend to have fewer work-related injuries than those with no knowledge of workplace ergonomic principles. This similar finding was reported among medical laboratory scientists [15]. Not surprisingly, a poor knowledge of good ergonomic principles contributes to the high prevalence of musculoskeletal disorders especially in professionals whose job task involves the use of manual handling [6 , 16].

Manual handling is defined as any activity requiring the use of force exerted by a person to lift, push, pull, carry or otherwise move, hold or restrain an animate or inanimate object [17]. Musculoskeletal injury is frequently associated with manual handling [12 , 18–20], especially among healthcare professionals such as nurses and physiotherapists whose jobs entails manual handling of patients or equipment [21 –25]. Particularly, physiotherapists and nurses have a high prevalence of WMSD [17]. This is because the job description of physiotherapists entails manual handling of patients during assessment and treatment sessions. Standing, bending or sitting over a long period of time in a particular position, working with physically dependent patients, and bearing a mechanical load during patient handling can result in a WSMD injury [26 –30].

Physiotherapists are widely educated in the field of ergonomics and therefore tend to trust their education and experience to help in the prevention of WMSDs during practice [31 –33]. Unfortunately, some studies have shown that even licensed and registered physiotherapists do not apply their knowledge of ergonomics in manual handling during practice [6 , 34–36]. This is caused by the lack of manual handling equipment in many establishments, negative attitudes of physiotherapist professionals toward ergonomic principles and the high patient case load in most practice settings [37].

In addition to the reasons stated above, the absence of specific ergonomic guidelines for the physiotherapy profession contribute to the high prevalence of WMSD among physiotherapists in Nigeria. This ergonomic guideline would act as a standardised resource to improve ergonomic awareness. Some studies have selectively assessed knowledge of manual handling among physiotherapists in a particular region of Nigeria [37], however, no nation-wide study with substantial sample size exists. In order to create a healthy and safe working environment for physiotherapists, a physiotherapy-specific ergonomics practice guideline is warranted. We believe that assessing the current levels of knowledge and practice of the ergonomic handling of patients during practice among physiotherapists in Nigeria is the first step towards creating a physiotherapy-specific ergonomic guideline. Therefore, the aim of this study is to determine the knowledge and practice levels of ergonomic principles in patient handling by physiotherapists practicing in Nigeria.

2 Method

2.1 Design and participants

Participants in this analytical cross-sectional descriptive survey were licensed physiotherapists in Nigeria as per the 2016 Annual Bulletin of the Medical Rehabilitation Therapist Board of Nigeria (MRTB [35]. Only physiotherapists with two or more years of practice experience after graduating from the entry-level physiotherapy training programs in Nigeria participated. In Nigeria, a physiotherapist after fulfilling the academic requirement of the entry-level physiotherapy training, writes the MRTB Examination. If satisfactory, the physiotherapist will be offered a provisional licence to practice under supervision of a professional licensed physiotherapist(s). The physiotherapist then proceeds to complete one year of the National Youth Service, before being offered the professional licence to practice as an independent physiotherapist.

From the listed physiotherapists in the MRTB bulletin (n = 3666) [36], a multi-stage sampling was applied. Since Nigeria has six geopolitical zones with 36 states and the Federal Capital Territory (FCT), we first assigned a random number to each state in the six geopolitical zones. We systematically selected 18 states with even numbers. All the licenced physiotherapists in the selected states received an email inviting them to participate in an online survey containing the questionnaire. An informed consent was embedded in the online survey; only respondents that provided an informed consent had access to complete the questionnaire. In order to maintain anonymity, respondents’ names and addresses were not requested in the questionnaire. A reminder was sent three times to each participant to participate in the survey [38 –40]. Ethical approval was obtained from the Health Research and Ethics Committee of the Lagos University Teaching Hospital while permission was obtained from the Medical Rehabilitation Therapists Board of Nigeria to access the Electronic Mail Database of physiotherapists in selected states in Nigeria.

2.2 Instrument

The main instrument for data collection was a questionnaire, adapted from previous studies [37, 41]. The questionnaire was modified and adapted to suit the purpose of our study. Content and face validity of the study tool were determined through a focus group comprised of seven experts with vast experience in academic, clinical, research and questionnaire development relating to Ergonomics. Reliability and internal consistency of the instrument was found to be Cronbach’s alpha of 0.77 for all the items whereas the items measuring knowledge and practice has a Cronbach’s alpha of 0.68 and 0.69 respectively. The questionnaire has 41 items, all close-ended questions, and was categorised into 3 sections, labelled A, B and C. Section A, has 8 items that collected the participants socio-demographic information. While section B (17 items) used a three-point Likert scale with options - ‘agree”, “disagree” or “I don’t know” to explore the knowledge of physiotherapists about ergonomic principles in patient handling, section C (16 items; of which 2 items has 4 sub-items and 3 sub-items each) used the same Likert scale to ask questions relating to the practice of ergonomic principles in patient handling. Participants were awarded one point for each correct answer and zero points for incorrect or unsure answers. Therefore, there is a total score of 17 and 28 (because of the sub-items from 4 questions) for section B and C respectively [41]. Participants were considered to have good knowledge and practice if they scored 50% and above of the total score of 17 and 28 respectively. For example, 9 out of 17 were considered good knowledge. Scores below 50% were considered poor knowledge [37].

2.3 Data analysis

The data was analysed using SPSS 21.0 version. Descriptive statistics were used for the demographics. Inferential statistics of Chi-square was used to determine any association between the socio-demographic characteristics and the levels of perceived knowledge and practice of ergonomic principles in patient handling among physiotherapists in Nigeria. Alpha level was set at <0.05.

3 Results

Of the 1,985 physiotherapists invited to participate in the online poll, only 567 responded, resulting in a 29% response rate. Of the 567 that responded, only 360 completed questionnaires were valid for analysis. Incomplete questionnaires were considered invalid for analysis. Table 1 described the demographic and their corresponding statistics for levels of knowledge and practice of ergonomic principles in patient handing among physiotherapists in Nigeria. Table 2 shows the levels of knowledge and practice of ergonomic principles in patient handling among physiotherapists in Nigeria respectively. While a high percentage (95.9%) of participants had a good level of knowledge, a lesser percentage (48.6%) had poor level of practice of ergonomic principles in patient handling in Nigeria. There was no significant association between the level of knowledge and practice of ergonomic principle in patient handling by the participants (Table 2). Among the demographic variables, area of practice showed a strong association with level of knowledge and practice. Years of physiotherapy practice and highest educational qualification showed significant associations with level of knowledge and practice respectively. Specific answers to questions for knowledge and practice of ergonomic principles in patient handling amongphysiotherapists in Nigeria are represented in Tables 3 and 4 respectively.

Table 1
Demographic variables of the participants and their corresponding statistical tests

Variable No (%) Statistical test

Level of knowledge Level of practice

Age

21–30 168(46.7)

31–40 157(43.6) X² = 4.780 (p = 0.578) X² = 7.891 (p = 0.086)

41–50 35(9.7)

Total 360(100)

Sex

Male 171 (47.5)

Female 189 (52.5) X² = 2.567 (p = 0.656) X² = 1.267 (p = 0.878)

Total 360(100)

Highest educational qualification

BPT/BMR 307(85.3)

MSc (43(11.9) X² = 6.400 (p = 0.094) X² = 8.267 (p = 0.041^)

DPT 4(1.1)

PhD 6(1.7)

Total 360(100)

Specialisation

Cardiopulmonary 035(9.7)

Community physiotherapy 05(1.4)

Ergonomics and occupational health 08(2.2)

Geriatrics 02(0.6) X² = 23.784(p = 0.002)^ X² = 53.610 (p = 0.000^)

Neurology 082(22.8)

Orthopaedics and Musculoskeletal 154(42.7)

Paediatrics 31(8.6)

Sports and recreation 02(0.6)

Women’s health 041(11.4)

Total 360(100).

Years of practice

1–5 247(68.8)

6–10 079(29.9)

11–15 24(6.7) X² 16.045 (p = 0.003) X² = 2.147(p = 0.709)

16–20 06(1.7)

>20 04(1.1)

Total 360(100)

Variable	No (%)	Statistical test
Age
21–30	168(46.7)
31–40	157(43.6)	X² = 4.780 (p = 0.578)	X² = 7.891 (p = 0.086)
41–50	35(9.7)
Total	360(100)
Sex
Male	171 (47.5)
Female	189 (52.5)	X² = 2.567 (p = 0.656)	X² = 1.267 (p = 0.878)
Total	360(100)
Highest educational qualification
BPT/BMR	307(85.3)
MSc	(43(11.9)	X² = 6.400 (p = 0.094)	X² = 8.267 (p = 0.041^*)
DPT	4(1.1)
PhD	6(1.7)
Total	360(100)
Specialisation
Cardiopulmonary	035(9.7)
Community physiotherapy	05(1.4)
Ergonomics and occupational health	08(2.2)
Geriatrics	02(0.6)	X² = 23.784(p = 0.002)^*	X² = 53.610 (p = 0.000^*)
Neurology	082(22.8)
Orthopaedics and Musculoskeletal	154(42.7)
Paediatrics	31(8.6)
Sports and recreation	02(0.6)
Women’s health	041(11.4)
Total	360(100).
Years of practice
1–5	247(68.8)
6–10	079(29.9)
11–15	24(6.7)	X² 16.045 (p = 0.003*)	X² = 2.147(p = 0.709)
16–20	06(1.7)
>20	04(1.1)
Total	360(100)

Notes : SD = standard deviation; X² = chi square test, ^*statistically significant, p < 0.05. Key: BPT – Bachelor of Physiotherapy; BMR – Bachelor of Medical Rehabilitation; PT – Physiotherapist; MSc – Master of Science; DPT-Doctor of Physiotherapy; PhD-Doctor of Philosophy.

Table 2

Association between Knowledge and Practice of Ergonomic Principles in Patient Handling

Categories	Levels of knowledge No (%)	Levels of practice No (%)	Statistical test
Good	344(95.6)	175(48.6)
Poor	16(4.4)	185(51.4)	X² = 0.013
Total	360(100)	360(100)	(p = 0.090)

Note: This is the percentage of the total sample.; X² = chi square test.

Table 3

Knowledge of ergonomic principles in patient handling

Questions	Correct n (%)	Incorrect n (%)
Patient handling is any activity used while treating a patient	303 (84.2)	056 (15.8)
Patient handling involves moving or lifting a body part of the patient	342(95.0)	018(5)
Patient handling involves moving or lifting a patient as a whole	307(85.3)	053(14.7)
Patient handling is activity requiring a force by a clinician to move a patient	193(53.6)	167(46.4)
My Physiotherapy training included ergonomic principles in handling Patients	315(87.5)	045(12.5)
Health and Safety at Work is an Act in Nigeria	249(69.2)	111(30.8)
Poor ergonomics in patient handling can predispose one to injury	359(99.7)	01(0.3)
Underarm lift is perfectly safe	084(23.3)	276(76.6)
Physiotherapist “Stance” is obsolete	206(57.2)	154(42.8)
Bear hug to facilitate standing is appropriate	061(16.9)	299(83.1)
Sliding patients up the bed without sliding sheets is a safe technique	237(65.8)	123(34.1)
Plinth must be adjusted to suit Physiotherapists’ height to aid transfer	349(96.9)	11(3.1)
Patient’s clothes should be held firmly in course of a transfer	100(27.8)	260(72.3)
I received sufficient Patient handling entry-level training	184(51.1)	176(48.9)
Entry-level training prepared me for Patient handling	269(74.7)	091(25.3)
Patient handling training must be carried out once a year	216(60.0)	144(40)
Competence in Patient handling increases with professional experience	0.64(17.8)	296(82.2)

^*Correct principles are highlighted in bold.

Table 4

Practice of ergonomic principles in patient handling

Questions	Correct n (%)	Incorrect n (%)
I use recommended ergonomic techniques	270(75.0)	90(25)
To ambulate a patient who requires more assistance, I
a) wait and continue later	270(75.0)	90(25)
b) find a commode	157(43.6)	203(56.3)
c) attempt to walk patient alone	258(71.7)	102(28.4)
d) ask ward clerk for help	231(64.2)	129(35.8)
To transfer 50 kg partial weight bearing patient from chair to bed
a) often do it alone, even if it is unsafe	287(79.7)	073(20.2)
b) practice underarm Lifting (assisting patient holding the axilla)	129(35.8)	231(64.2)
c) often call for assistance	278(77.2)	082(22.7)
Pt slipped down the bed and needs re-positioning, I
a) slide patient up using bed sheets	163(45.3)	197(54.7)
b) slide up with underarm grip	117(32.5)	243(67.5)
c) leave patient alone and try to locate a sliding sheet	29(8.1)	331(91.9)
Pt begins to fall during a mobility session, I
a) step away so I do not injure myself	345(95.8)	15(4.2)
b) attempt to catch patient	069(19.2)	291(80.8)
c) try to guide patient in fall to the floor	176(48.9)	184(51.1)
There is sufficient space in handling areas to perform tasks	140(38.9)	220(61.1)
My unit has a ‘No-Lift’ PH policy	067(18.6)	293(81.4)
The equipment I need is available when I need	079(21.9)	281(78.1)
I allow enough time for PH tasks	235(65.3)	125(34.8)
I purposely rotate my handling tasks	169(46.9)	191(53.1)
I take breaks in between tasks	239(66.4)	121(33.6)
My equipment can be easily moved over the floor surface	206(57.2)	154(42.8)
I always assume a straight back when Static posture is required	297(82.5)	063(17.5)
Sometimes I assume Awkward posture due to equipment in use	153(42.5)	207(57.5)
Often times I have no choice but to lift patients alone	104(28.9)	256(71.1)

^*correct principles are highlighted in bold.

4 Discussion

The study investigated the knowledge and practice of ergonomic principles in patient handling among physiotherapists in Nigeria. In general, the majority of physiotherapists in Nigeria had a good knowledge of ergonomic principles in patient handling but had poor practice level. Male predominance as observed in the study has validated a continuous shift of the physiotherapy profession from an initially female dominated to a male dominated profession in Nigeria [42, 43].

Most of the participants in our study had a good knowledge of ergonomic principles of patient handling. This is consistent with previous studies that surveyed the knowledge of manual handling, ergonomics and biomechanics among other health care professionals [29, 41]. The majority of respondents in our study agreed that physiotherapy tasks often require moving and maintaining certain positions for a long time. This finding is consistent with other studies [27–30 , 44]. Most respondents reported having adequate knowledge about work postures/positions and bed height level needed for patient transfer and treatment. Previous investigators have documented that knowledge of bed height adjustments during transfer and treatment is an important component of manual handling of patients in bed [45, 46]. Therefore, it is rather comforting to note that physiotherapists in Nigeria reported an adequate knowledge of bed height adjustment during transfer. Furthermore, physiotherapists in this study did consider it safe to slide patients up the bed with the use of sliding sheets. This finding is in tandem with the findings of [27, 37], that reported that physiotherapists considered the use of sliding sheets in moving patients up the bed as a safe method. Physiotherapists in our study consider standing in a lunge position to be safe during patient handling. Lunge position has been considered biomechanically sound for handlers and serves as a better position to prevent musculoskeletal injuries [47]. Our findings agree with a study by Cromie [34] that reports knowledge of patient handling and therapist safety during treatment is one of the courses taught in entry-level physiotherapy training programs inAustralia.

Whereas the knowledge of patient handling was good, participants often did not uphold good practice principles. Even though this finding is consistent with Swain et al. [48] study, it is of note that most of the questions that explore practice were workplace limitations. Most times, physiotherapists do not have control over some of the workplace limitations. For instance, most of the participants reported that their practice settings do not have mechanical “lifts”, therefore they manually lift a “heavy” patient off the bed. These workplace limitations could be one of the reasons why there is a gap between the level of knowledge and practice of patient handling among physiotherapists in Nigeria. It is possible that amending the limitations in the workplace with appropriate equipment would improve practice of patient handling among physiotherapists inNigeria.

Our findings, consistent with the literature, provided an insight into the possible factors affecting the reported knowledge and practice of patient handling. First, the area of specialisation of the participants showed a significant association with the level of knowledge and practice reported by the respondents. This agrees with existing evidence that explored the role of professional specialization on levels of knowledge and/or practice [6, 49–51]. Educational attainment however did not have any significant association with knowledge, suggesting that knowledge acquired at the undergraduate level could be sufficient. This corroborates some previous findings [30, 37]. It is also possible that the unequal distribution of participant’s level of education would have affected the result of no significant association between level of education and knowledge of ergonomic principles in handling patient.

Surprisingly, there was no significant association between years of physiotherapy practice and the practice of ergonomic principles. This further supports our previous argument that workplace limitations may be one of the major reasons for poor practice of ergonomic principles in patient handling among physiotherapists in Nigeria. Therefore, we suggest that removing workplace limitations could be a good strategy to increasing the level of practice of ergonomic principles in patient handling among physiotherapists in Nigeria.

5 Study limitations and strengths

The poor response rate, as a study limitation could hinder making generalizations about the findings of this study. Also, we were not able to conduct objective validations of the instrument. However, the reliability coefficient although not excellent gives a good idea of the reliability of the instrument. This study would have been strengthened if we were able to determine which of the areas of specialisation showed significant association with knowledge and practice levels. This area should be explored by researchers for further studies.

6 Conclusion

Most of the physiotherapists in Nigeria have good knowledge of ergonomic principles in patient handling. Few physiotherapists in Nigeria practiceergonomic principles when handling patients despite having the knowledge. There was no significant association between knowledge and practice of ergonomic principles in patient handling among physiotherapists in Nigeria. There is a wide knowledge-practice gap in patient handling among physiotherapists in Nigeria. There was significant association between knowledge, specialisation and years of practice with younger practitioners having less knowledge than older ones in the profession, but no significant association between knowledge and highest educational attainment was discerned. Highest educational attainment and specialisation also have a significant association with practice of ergonomic principles in patient handling. Years of practice has no significant association with practice of ergonomic principles in patient handling among physiotherapists in Nigeria.

Conflict of interest

No conflicts of interest were reported.

Footnotes

Acknowledgments

Worthy of note are the contributions made by Dr A.I. Aiyegbusi, Mrs E.L. Ndionuka, Mr C.A. Adeagbo, Miss N.C. Monye and Mr. Rick Downes. We greatly appreciate their input in this work.

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