Knowledge and Practice of Body Mechanics Techniques Among Nurses in Hospital Kluang, Johor, Malaysia.

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1 Title: Knowledge and Practice of Body Mechanics Techniques Among Nurses in Hospital Kluang, Johor, Malaysia. Authors: 1. Jaafar N Faculty of Nursing, Allied Science and Health, Open Unversity Malaysia. 2. Mohd Ghazali AN Ledang District Health Office, Johor, Malaysia.

2 ABSTRACT Body mechanics will be more effective in nurses if they know how to use it as well as practice it in correct way while performing procedures that require its use. This study was a cross sectional study using a set of questionnaires, carried out to determine the knowledge and practice of body mechanics techniques among nurses. Our aims for these studies are: to determine the knowledge and practice of nurses towards body mechanics techniques and the obstacles that encountered by nurses. Almost all nurses have the knowledge about body mechanics techniques but did not practice it for their personal reasons. In this study, it was found out that 100 percent of nurses were have the knowledge towards body mechanics techniques percent of them aware that practicing correct body mechanics techniques was important for them and 31.8 percent were not. The findings of the study indicated that majority of nurses were have the knowledge about body mechanics techniques but less practicing on it. However, some of them still lack of knowledge caused them did not practice correct body mechanics techniques while in clinical area. Staff nurses should more aware and know the knowledge of body mechanics techniques as well as practicing it for their own good. Keywords: Body mechanics, nurses, knowledge, practice.

3 1.0 INTRODUCTION Body mechanics is a term used to describe the ways we move as we go about our daily lives. It includes how we hold our bodies when we sit, stand, lift, carry, bend, and sleep. Poor body mechanics are often the cause of back problems. When we do not move correctly and safely, the spine is subjected to abnormal stresses that over time can lead to degeneration of spinal structures like discs and joints, injury, and unnecessary wear and tear. That is why it is so important to learn the principals of proper body mechanics. Proper body mechanics are vitally important for keeping our spine healthy. And it is easy to incorporate these principals into our daily life. It may seem unnatural at first, but if we keep at it, they will easily become routine and our back will thank us for it. Good body mechanics means using the safest and most efficient methods to lift and move patients or heavy items. Efficiency is more important than strength. Most people are aware that when they bend or lift something, they should bend their knees. While it is important to bend the knees, attention must also be paid to the position of spine. In order to avoid injury, either at the moment of lifting something or, more likely, as a result of poor body mechanics over time, care must be taken to maintain the neutral spine. A neutral spine means that the three normal curves-at the neck, middle and lower back-are maintained. When viewed from the outside, the back looks straight with a hollow in the low back. Everyday activities can place undo stress on the spine. Learning how to use good body mechanics will minimize these stresses and decrease the incidence of back and neck injuries. Good body mechanics are not just for the work site but should be used at all times. Musculoskeletal disorders are an important public health problem. Among them are back conditions, a complex problem for certain occupational groups, such as nursing personnel. Historically, back pain has been a major complaint, and nursing professionals are one at the highest risk. Risk factors for back pain can be either of individual origin or related to the work place. The main occupational risk factors are lifting and handling of patients, uncomfortable and immobile postures, inadequate equipment, improper work place design, heavy physical work and inadequate work organization. A study conducted by J A Engel et al, on the topic of work related risk factors for musculoskeletal complaints in the nursing profession; `results of a questionnaire survey found that a large proportion of the subjects regularly had back complaints 36% but also had arm or neck 30% and leg complaints 16%. Almost all respondents (89%) considered nursing work as physical strenuous.

4 One of the most important aspects of patient care is to ensure safety for each patient throughout the day. It is impossible to prevent accidents completely. However, there are ways to limit the potential for accidents that may cause injury to the patient or health care personnel and the unnecessary loss of equipment. Nurses can increase body balance when working the body movement requires coordinated muscle activity and neuralgic integration. Mainly basic elements is body alignment the proper alignment enhances lung expansion and promotes efficient circulatory renal and GI function Some of the most common injuries sustained by members of the health care team are severe musculoskeletal strains. Many injuries can be avoided by the conscious use of proper body mechanics when performing physical labor. The goal of nursing is healing the sick, so it s ironic that nursing as a profession sees some of the highest rates of musculo-skeletal injuries. A musculo-skeletal injury might disrupt a nurse s career. There are many nurses who love direct patient care but have been forced to either leave nursing or leave the type of nursing they enjoy because of injury. Protective and defensive postures, positions and body mechanics, results in natural strengthening of the back, erases the muscle strain and minimizes the chances of musculoskeletal problems of back among Staff Nurses. Nursing staffs have one of the highest incidences of work-related back problems of all occupations. There must be proper alignment in order to have proper movement. Some of the most common injuries sustained by members of the health care team are severe musculoskeletal strains. Many injuries can be avoided by the conscious use of proper body mechanics when performing physical labor. Fact sheet presented at The ANA s Handle with Care Campaign, (2003), which was intended to develop and implement a proactive, multi-faceted plan to promote the issue of safe patient handling and the prevention of musculoskeletal disorders among nurses in U.S, reported that patient handling tasks are recognized as the primary cause for musculoskeletal disorder among the nursing workforce. During the stressful situations, even the most experienced staff member can forget the importance of ergonomics. So nurses are at an increased risk for work-related musculoskeletal injuries as a result of the cumulative effects of manual patient-handling tasks. According to statistical records, The Occupational Safety and Health Administration (OSHA) have calculated that nearly half of all health care workers suffer at least one work-related musculoskeletal injury during their career. More than half of all nurses (52%) complain of chronic pain and 38% of registered nurses (RNs) have suffered occupation related back injuries severe enough to require time away from work.

5 Nelson, Fragala, and Menzel (2003) identified 10 stressful patient-handling tasks often performed by nurses as well as nursing students that place them at risk for musculoskeletal injuries. These include bathing a patient in bed; making an occupied bed; dressing a patient in bed; transferring a patient from bed to stretcher, wheelchair, or geriatrics chair; repositioning a patient in a chair; pulling a patient up to the head of the bed; and putting anti embolism stockings on a patient. According to Menzelet. al., musculoskeletal injuries can begin in nursing schools, with clinical activities that require lifting heavy patients, sustained awkward positions, and repeated stressful movements. Nurses need to educate themselves on how and why patient lifting causes spinal injury. It has long been said that for nurses "back injury is part of the job" without clearly defining "back injury." Nurses need to know that manually lifting patients places them at tremendous risk of permanent spinal disability, not just at risk of muscle strain, which would be expected to heal in a matter of days or weeks. Despite the known of the important of body mechanics techniques, there are nurses who are still not practicing correct body mechanics techniques because of certain obstacles and reasons. Thus, this paper will study The Knowledge and Practice of Body Mechanics Techniques among Nurses at Kluang Hospital. This survey helps to reveal their understanding toward body mechanic techniques. 1.1 Research Problem The study is primarily concerned with knowledge and practice of correct body mechanic techniques among nurses; to assess nurses knowledge about the body mechanic techniques; and to determine the causes why nurses do not practice correct body mechanics techniques. Following the discussion above question: What is the reason of nurses do not practice correct body mechanics techniques? What are the implementations to make the nurses practicing correct body mechanics techniques? Therefore, the significance of the study will be to analyze the knowledge about practice of body mechanics techniques among nurses at Hospital Kluang, Johor. Most of the nurses found that it was difficult to do proper body mechanics because lack of knowledge and less practicing body mechanics from the data gathered recommendations can be suggested and of

6 course the most we want every student nurses will start practicing correct body mechanics techniques. 1.2 Objectives Of The Research General Objective To analyze the knowledge and practice of nurses towards body mechanics techniques To determine the obstacles that preventing nurses from practicing correct body body mechanics techniques Specific Objectives To measures the knowledge of the nurses about the importance of body mechanics techniques. To collect data about the behavior and practice of nurses towards body mechanics techniques. To determine the causes and obstacles that preventing nurses from practicing correct body mechanics techniques. 1.3 Research Questions Does the use of body mechanics can reduce back pain? Do you agree with the statement below: -

7 Lifting patients or heavier is better to use a bed sheet from a mass hand If you do not maintain good posture while doing the procedure. Do you have back pain? * Maintain the proper body function. * Reduce the strain / spasm. * Maintain the balance. The above statement explains the importance of body mechanics practice. Do you agree? Does body mechanics use continuous muscle? Object must be close to the gravity. Do you agree with the statement above? Does the use of continuous muscle tension and injuries cause musculoskeletal pain? The principles of body mechanics, the act of attractive may produce less friction than reject. Do you agree? Are the injuries can be avoided through the body mechanics? Do you know the purpose of using body mechanics? Does heavy work activities like bending, twisting and frequent heavy lifting contribute to low back pain? Improper usage of body mechanics techniques can cause spinal injury? Does attire e.g shoes play an important role to influence back pain? What are the complications related to improper use of body mechanics? Are you asking for help from a friend if you have to lift big patient? Do you straighten your knees and bending your back when lifting an object from the floor? Are you using the principles of body mechanics during the procedure for removing a patient from bed to chair? Are you closing the legs when moving patients in the bed? Do you experience any back pain before? Do you wearing proper attire during working time? Do you know what is body mechanics all about? Do you practice body mechanics all the time during working time? What are the difficulties/barriers that you encontered in practicing body mechanics?

8 1.4 LITERATURE REVIEW

9 Review of literature is a key step in the research process. Review of literature refers to an extensive, exhaustive and systematic examination of publications relevant to the research project. Review of literature for the study has been organized under the following Headings: Study related to nurses knowledge on body mechanic. The study was conducted in School of Nursing, Purdue University in West Lafayette, Indiana, USA regarding high prevalence of back injury and subsequent back pain in nursing, which explored multidimensional factors with respect to working behaviors, physical fitness, and environments that contribute to both acute and cumulative back injuries to nursing staff. Specific interventions to reduce the risk for back injury are examined. The practice of proper posture, body mechanics, and lifting techniques are reviewed. Exercises to increase flexibility, muscle strength, and endurance are encouraged to reduce the gap between job physical demands and human capabilities. Nurses were also encouraged to be knowledgeable about ergonomic principles and to be active in identifying and using these principles. Research needs and approaches to the study of the back injury problem of nurses were also suggested. The study was conducted in the department of nursing among Turkish hospital workers including nurses experiencing low back pain because of heavy work activities like bending, twisting and frequent heavy lifting. The Highest prevalence was reported by nurse (77.1%) Hospital aids (53.5%). (Majority of the nurse used by the body mechanics correctly while sitting (53.6%) standing 53.7% carrying 64.3% pulling or pushing 79.4% moving the patient to the side of the bed without an assistant 53.4% moving the patient to a sitting position in ed. 71.4% and assisting the patient to a standing position (66.6%) 57.1% of the nurses lifted and extended incorrectly nurses do not use body mechanics correctly and the majority have low back pain. The study emphasized on taking preventive measures such as educational programmed to teach the proper use of body mechanism Study related to nurses practice on body mechanics techniques

10 According to Aziza Ismail in the book stating basic nursing body mechanics is an efficient way of using the body as a machine for movement. This is supported by a study conducted by Moody J et al (1996), where 62% of nurses in the normal ward nurses and 71% of the elderly care wards and the Cardiac Care unit (CCU) stated that they have back pain while working in the ward. While according to Moses (1992) and Owen (1989) in his study shows each year 12% of nurses would prefer to move jobs to reduce the risk of back pain and 12% -18% is leaving nursing because of chronic back pain condition. National Institute for Safety and Health Occupational (NIOSH) has issued a Work Practices Guide for Manual Lifting in 1981, to introduce healthy workers without the risk of back pain. This guideline has proven important to practice proper body mechanics on the job can reduce the risk of back pain, including nurses. Following the practice of awareness about the importance of body mechanics, American Nurse Association, Handle With Care Campaign launched in 2003 that emphasizes measures to prevent back pain and musculoskeletal injuries by adopting the proper position when providing care to patients. According to Audrey Nelson et al (2004) in the journal Evidence-Based Practices for Safe Patient Handling and Movement said that changes in the environment, layout of equipment and work environment is one way to overcome problems related to musculoskeletal injuries. Study Maras et al (1999) has shown that the clinical task at a high risk of spinal injuries as a result of not practicing proper body mechanics. According to the Annual Journal Nursing (AJN) September (2006) by Hans-Peter de Reiter, Texas and Washington have been approved by - laws for the implementation of safe patient handling policies of hospitals and other healthcare institutions. The goal of this law is to reduce the incidence rate increased musculoskeletal injuries as experienced by nurses as a result of patient handling and transfer. In addition, it also aims to prevent injuries to patients. Among the laws that are set forth explicit requirements for the implementation of the use of body mechanics in the treatment of patients. An explorative study was designed to identify the usage of body mechanics in clinical settings and the occurrence of low back pain among 56 nurses working in the medical, surgical, emergency and intensive care units of a state hospital in Bolu, Turkey. Data collected through observation and interviews. Results of the study showed that the majority of the nurses (87.5%) experienced low back pain at some time in their lives. Among the contributing factors for back pain, the relationship between wearing high heels, heavy lifting and back pain was significant statistically. According to the observations, the majority of the nurses used body mechanics correctly while sitting (53.6%), standing (58.7%), carrying (64.3%), pulling

11 or pushing (79.4%), moving the patient to the side of the bed without an assistant (53.4%), moving the patient to a sitting position in bed (71.4%) and assisting the patient to a standing position (66.6%). However 57.1% of the nurses lifted and 82% extended incorrectly. The study concludes that some of the nurses do not use body mechanics correctly and the majorities have low back pain. A study was conducted to examine the staff injuries associated with the patient handling of the obese, and to describe a process for identifying injuries associated with their mobilization, and to report on the need for safer bariatric patient handling in a 761- bed, level 1 trauma center affiliated with a U.S. medical school. The study results revealed that during 2007, although patients with a body mass index of > or =35 kg/m (2) constituted <10% of our patient population, 29.8% of staff injuries related to patient handling were linked to working with a bariatric patient. Bariatric patient handling accounted for 27.9% of all lost workdays and 37.2% of all restricted workdays associated with patient handling. Registered nurses and nursing assistants accounted for 80% of the injuries related to bariatric patient handling. Turning and repositioning the patient in bed accounted for 31% of the injuries incurred. 19. Are the injuries can be avoided through the body mechanics? A study was conducted to identify high risk for musculoskeletal disorders on five critical care units (two surgical ICUs, two medical ICUs, and one cardiac ICU) at two large medical centers in VAMC Tampa, to identify tasks with high risk for musculoskeletal disorders. The criteria used to identify potential high risk for WMSDs for critical care tasks included (1) high force, (2) awkward postures, or (3) repetitive loading. Data were collected through direct observation of physical work environment, technology, and work practices; digital photography; interviews with ICU nurses and nurse managers; and a 2-year review of WMSDs reported in ICUs. The study concludes that seven high-risk patient handling tasks in critical care were identified as having high risk for musculoskeletal disorders. These include; pushing occupied beds or stretchers, lateral patient transfers (e.g., bed to stretcher), moving patients to the head of a bed, repositioning patients in bed (e.g., side to side), making occupied beds, applying ant embolism stockings, lifting or moving heavy equipment. Also a study was conducted to evaluate the effectiveness of an intensive educational and low-tech ergonomic intervention programmer aimed at reducing low back pain (LBP) among the 345 home care nurses and nurses aides in four Danish municipalities. Participants in two municipalities constituted the intervention group and participants in the other two served as the control group. In the intervention group, participants were divided into small

12 groups, each of which was assigned one specially trained instructor. During weekly meetings participants were educated in body mechanics, patient transfer, and lifting techniques, and use of low-tech ergonomic aids. In the control group, participants attended a onetime only threehour instructional meeting. Information on LBP was collected using the Standardized Nordic Questionnaire supplemented with information on number of episodes of LBP and care seeking due to LBP during the past year. A total of 309 nurses and nurses' aides returned the questionnaire at baseline and 255 at follow up in August At follow up, significant differences were found between the two groups for the LBP variables, and both groups thought that education in patient transfer techniques had been helpful. A study was conducted to illuminate nursing staff's perception of changes after a course in patient transfer in Karolinska Institute, Sweden. The learning process took the form of self-experience focusing on the manner of supporting the patient to move independently. A total of 20 participants, who had answered a previously administered questionnaire, were chosen for interviews. The themes concerned the meaning of changing transfer habits. A phenomenological-hermeneutic analysis method showed that changes focused on the patient's body, the staff member's own body or cooperation with the patient. Awareness of one's own body and confidence in one's own ability seem to indicate differences in the manner of supporting the patient to move. The changes in transfer habits varied in content and meaning from person to person, depending on the focus during the transfer. These findings can contribute to an understanding of how change takes place after an educational intervention. A study was conducted to assess the manual handling practices and injuries among Intensive Care Units (ICU) nurses working in an Austin & Repatriation medical centre in Australia. The objectives of this study were to identify patterns of manual handling activities; the incidence, types of injury and body site injured; and establish the consequences of injuries. The study revealed that the rate of manual handling injuries among ICU nurses was unacceptably high (52.2%), as was back injury (71.4% of all injuries). In order to reduce manual handling injuries the study recommended employers to provide lifting assistance devices; design workplaces so as to minimize the need for ICU nurses to twist, bend and/or lift items from the floor; introduce regular equipment maintenance procedures; provide adequate staffing to assist with lifting patients; and implement processes that facilitate more detailed statistics on manual handling activities and outcomes.

13 A study was conducted to evaluate three brands of commercially available nursing footwear and identify the important shoe features for adequate shoe support during nursing activities, and to assess the effect of wearing compression hosiery by measuring the biomechanical, physiological, and psychophysical responses of test participants at Hua University, Taiwan. Firstly, field observations were conducted to collect job demand data, including walking speed, and the ratios of walking, standing, and sitting. Secondly, an experiment was conducted to evaluate the functions of professional nursing footwear and examine the influence of compression hosiery on lower extremity discomfort relief. The findings of this study reveals that, comfortable footwear for nursing professionals should emphasize a foot bed with arch support outside with 1.5 cm thickness of EVA materials in the metatarsal zone and heel height between 1.8 and 3.6 cm; this can minimize foot pressure distribution, impact force, and increase shin and ankle comfort. In addition, wearing compression hosiery is recommended to alleviate lower body and foot discomfort for clinical nurses. A study was conducted to describe the routine activities performed during day and night shifts, and to compare the work activities performed in different wards during these shifts, among 83 practical nurses working at the Orthopedics and Trauma Institute, Brazil. Forty-three of them (52%) reported pains or musculoskeletal diseases, either based on their own opinion or diagnosed by a physician. These nurses were invited to join the second phase of the study and twenty-nine accepted it. All work activities performed in 29 shifts were observed and recorded. The results showed that day shifts were far more demanding in terms of the number of activities related to patients' care than afternoon and night shifts. Also, body postures associated with day work activities demanded important physical efforts. The number of nurses in charge during night shifts was substantially lower than during day shifts. This could lead to an overload and affect the health of the nurses Study related demonstration programmed to minimize the injuries among nursing personnel. The study were conducted in College of Nursing, University of Nevada Las Vegas by Nursing educators who teach outmoded manual patient handling techniques to prevent the widespread problem of musculoskeletal disorders in student and practicing nurses. The

14 authors discuss the development and implementation of a new safe patient handling curriculum module, which was pilot tested in 26 nursing programs. The module changes the focus of patient handling education from body mechanics to equipment-assisted safe patient lifting programs that have been shown to protect nurses from injury and improve care. The study to evaluate the effectiveness of an intensive educational and low-tech ergonomic intervention programmed aimed at reducing low back pain (LBP) among 345 home care nurses and nurses' aides were conducted in four Danish municipalities. Participants in two municipalities constituted the intervention group and participants in the other two served as the control group. In the intervention group, participants were divided into small groups, each of which was assigned one specially trained instructor. During weekly meetings participants were educated in body mechanics, patient transfer, and lifting techniques, and use of low-tech ergonomic aids. In the control group, participants attended a onetime only three hour instructional meeting. Information on LBP was collected using the Standardized Nordic Questionnaire supplemented with information on number of episodes of LBP and care seeking due to LBP during the past year. Total results of 309 nurses and nurses' aides returned the questionnaire at baseline and 255 at follow up in August At follow up, no significant differences were found between the two groups for any of the LBP variables, and both groups thought that education in patient transfer techniques had been helpful Study related to complications of improper body mechanics. Back injuries are a serious problem for nursing personnel who perform frequent patient-handling activities. This study was conducted in department of Occupational and Environmental Medicine, Health Sciences Centre, Winnipeg, Canada. Common prevention strategies include body mechanics education, technique training, and ergonomic interventions such as the introduction of assistive equipment. This investigation assessed and compared the effectiveness of two patient-handling approaches to reducing injury risk. One strategy involved using improved patient-handling technique with existing equipment, and the other approach aimed at eliminating manual patient handling through the use of additional mechanical and other assistive equipment. Both intervention arms received training in back care, patient assessment, and use of the equipment available on their particular wards. An analysis of compliance with interventions and the effects of patient-handling methods on both peak and cumulative spinal compression and shear during various tasks were conducted.

15 Results showed greater compliance with interventions that incorporated new assistive patienthandling equipment, as opposed to those consisting of education and technique training alone. In several tasks, subjects who were untrained or non-compliant with interventions experienced significantly higher peak spinal loading. However, patient-handling tasks conducted with the aid of assistive equipment took substantially longer than those performed manually. This, along with variations in techniques, led to increases in cumulative spinal loading with the use of patient-handling equipment on some tasks. Thus, the use of mechanical assistive devices may not always be the best approach to reducing back injuries in all situations. No single intervention can be recommended; instead all patient-handling tasks should be examined separately to determine which methods maximize reductions in both peak and cumulative lumbar forces during a maneuver. The study was conducted in department of work and health, national institute in working life, of staff nurses to explore the work technique applied by them in patient transfer task. The work technique used by 1or 2 nurses to patient transfer in orthopedic ward the score indicated the level of muscular safety hazards. The result is poor work technique and low back symptoms. The use of body mechanics to lift and move patients among trainee nurses had been much debate in recent times. Center of gravity is moving in the position of the body and this teaches us to use axes, large muscles strong and body position, and use the wheel to lift or move an object. All these practices will be launching a body of work and avoid injuries Studies related to occupational injuries among nurses. Sienkiewicz Z, Paszek T, Wronska I, (2007) conducted a study on Strain on the spine- -professional threat to nurses' health. Research was carried out on a group of 937 nurses working in health care units in the Warsaw district area. The study was conducted using the method of diagnostic survey and as a research tool a questionnaire sheet including 70 questions divided into 6 categories was used. Research was carried out voluntarily and anonymously.79% of tested people fears of degenerative changes of the spinal column. Health problems that are connected to lower back pain are reported by 61% of nurses. 67% of ward nurses and 79% of scrub nurses, more often than departmental nurses and these working in other basic and specialized units, complain about pain symptoms after duty. The greatest strain placed on the spine affects tested nurses working in gastrology department (74%), department of internal medicine and neurology department (70%).

16 Derek R. (2004) conducted a study on musculoskeletal disorders among professional nurses in Mainland China. They investigated 180 nurses (84.1 percent response rate) from a teaching hospital using a previously validated, self-reporting musculoskeletal disorder survey. The overall prevalence of musculoskeletal disorders was 70.0 %, with individual categories reported as follows: lower back (56.7%), neck (42.8%), shoulders (38.9 %t) and upper back (38.9 %). Period pain was shown to increase the risk of musculoskeletal disorders 23.8 times (odds ratio [OR] 23.8; 95 percent confidence interval [CI], ; P =.0008). Excessive mental pressure incurred a 10.5-fold risk increase (OR 10.5; 95 percent CI, ; P =.0058). Interestingly, occasional consumption of alcoholic drinks reduced the risk of musculoskeletal disorders 10-fold (OR 0.1; 95 percent CI, ; P =.0046), as did working in the gynecology department (OR 0.1; 95 percent CI, , P =.0240). Overall, study showed that musculoskeletal disorders are common among nursing professionals in mainland and represent an important occupational issue for this Asian demographic. Smith DR (2003) conducted a study on musculoskeletal disorders among female nurses in a rural Japanese hospital. Data were gathered by means of a self-reporting questionnaire from 305 female staff nurse. Lower back pain (LBP) was the most commonly reported MSD, affecting 59% of all nurses. This was followed by MSD of the shoulder (46.6%), neck (27.9%), knees (16.4%) and upper leg (11.8%). Working in the surgical department was shown to increase the risk of any MSD 2.7 times when compared to nurses in the other departments (odds ratio 2.7, 95% confidence interval , P = ). Overall, study shows that MSD are reasonably common among registered nurses in a rural Japanese hospital. Yassi A (2001) conducted a study on randomized controlled trial to prevent patient lift and transfer injuries of health care workers, to compare the effectiveness of training and equipment to reduce musculoskeletal injuries, increase comfort, and reduce physical demands on staff performing patient lifts and transfers at a large acute care hospital. The method of data collection was Randomized controlled trial (RCT). This three-armed RCT consisted of a "control arm," a "safe lifting" arm, and a "no strenuous lifting" arms. A medical, surgical, and rehabilitation ward were each randomly assigned to each arm. Both intervention arms received intensive training in back care, patient assessment, and handling techniques. Hence, the "safe lifting" arm used improved patient handling techniques using manual equipment, whereas the "no strenuous lifting" arm aimed to eliminate manual patient handling through use of additional mechanical and other assistive equipment. Frequency of manual patient

17 handling tasks was significantly decreased on the "no strenuous lifting" arm. Self-perceived work fatigue, back and shoulder pain, safety, and frequency and intensity of physical discomfort associated with patient handling tasks were improved on both intervention arms, but staff on the mechanical equipment arm showed greater improvements. Musculoskeletal injury rates were not significantly altered. Yip Y (2001) Conducted a cross sectional study of work stress, patient handling activities and the risk of low back pain among 377 nurses in Hong Kong. This study aims to measure the magnitude of LBP among nurses and its association with the work-related psychological strain and patients handling activities. A cross-sectional study of hospital nurses was conducted. The samples were registered nurses or enrolled nurses working fulltime for at least 1 month in the current ward, recruited from 6 district hospitals. Data were collected by face-to-face interviews. The data included work factors, demographics, psychological distress and lifestyle factors and the occurrence of LBP. Of the 377 nurses interviewed, 153 (40.6%) reported having LBP within the last 12 months. With symptoms of LBP as the outcome, risks were increased where nurses self-reported that they only occasionally or never enjoyed their work [adjusted odds ratio (OR) 2.07], where frequent manual repositioning of patients on the bed was required (adjusted OR 1.84) and where they were required to assist patients while walking (adjusted OR 2.11) after adjustment for other potential confounders. The results indicate that an association exists between work stress, manual lifting and LBP prevalence. Good posture and correct transferring techniques in ward situations should be reinforced with hands-on practice performed on nurses' common types of clients. Engels JA et al, (1996) conducted a study on Work related risk factors for musculoskeletal complaints in the nursing profession, Netherlands. The aim was to determine the prevalence of musculoskeletal complaints of the back, arms or neck, and legs among nurses, and to investigate the relation between these complaints and various work related and personal variables. A questionnaire survey was carried out in four nursing homes in The Netherlands. The response was 95% and resulted in 846 completed questionnaires. It was found that a large proportion of the subjects regularly had back complaints (36%) but also had arm or neck (30%) and leg complaints (16%). Almost all respondents (89%) considered nursing work as physically strenuous. Most of them complained of working under time pressure (69%), increased work pressure (70%), and having no opportunity to take a break from the work (70%). The physical variables, which seem to trouble the subjects most were lifting (65%),

18 working in awkward postures (47%), and stooping (34%). Moreover, 53% of the subjects responded that the ergonomic lay out of the ward was disagreeable. From these results it may be concluded that future research of health risks of nursing work should have a wider focus than the relation between physical workload and low back pain Studies related to body mechanics: Freitag S et al, (2007) conducted a study on Quantitative measurement of stressful trunk postures in nursing profession. In this study all the body postures and movements of nurses were quantitatively measured within a working shift. The body postures were recorded with the CUELA measurement system (computer-assisted recording and long-term analysis of musculoskeletal loads), coupled to the individual, and this detected all movements of the trunk and the legs. Video recordings supported these measurements, so that exact allocation of the measured data to the tasks performed was possible. In all, 24 shift measurements were carried out in 8 wards. Extent, frequency and duration of trunk postures were measured in three planes and assessed on the basis of several standards A mean of 1131 (+/-377) trunk inclinations of >20 degrees were performed in each shift. This corresponds to a frequency of 3.5 min (-1). A total of 237 of these inclinations lasted for >4 s. A total of 72 (+/-35) min was spent bending forward with an inclination of >20 degrees. However, the mean time spent in transferring patients (counting only the lifting process) and heavy materials was only 2 min per shift. Postures with trunk inclination of >60 degrees were adopted for a mean of 175 (+/- 133) times. The main tasks responsible for this were 'bed making' (21%), 'basic care' (16%) and 'clearing up/cleaning' (16%). It could be shown that many stressful trunk postures are assumed in nursing work during a shift. Karahan.A (2006) conducted an explorative study about action of the usage of body mechanics in clinical settings and the occurrence of low back pain in 56 nurses at Turkey. The sample was composed of 56 nurses who work on the medical, surgical, emergency and intensive care units. Data collected through observation and interviews were evaluated using percentages, Chi-square and Mann-Whitney U tests. Results of the study showed that the majority of the nurses (87.5%) experienced low back pain at some time in their lives. Among the contributing factors for back pain, the relationship between wearing high heels, heavy lifting and back pain was significant statistically. According to the observations, the majority of the nurses used body mechanics correctly while sitting (53.6%), standing (58.7%), carrying

19 (64.3%), pulling or pushing (79.4%), moving the patient to the side of the bed without an assistant (53.4%), moving the patient to a sitting position in bed (71.4%) and assisting the patient to a standing position (66.6%). However 57.1% of the nurses lifted and 82% extended incorrectly. The conclusion from this research was that some of the nurses do not use body mechanics correctly and the majority has low back pain. Retsas A, Pinikahana J, (2003) conducted a study on Manual handling practices and injuries among ICU nurses in Australia. The objectives of this study were to identify patterns of manual handling activities; the incidence, types of injury and body site injured; and establish the consequences of injuries. The rate of manual handling injuries among ICU nurses was unacceptably high (52.2%), as was back injury (71.4% of all injuries). In order to reduce manual handling injuries, employers should provide lifting assistance devices; design workplaces so as to minimize the need for ICU nurses to twist, bend and/or lift items from the floor; introduce regular equipment maintenance procedures; provide adequate staffing to assist with lifting patients; and implement processes that facilitate more detailed statistics on manual handling activities and outcomes. Wilson C. B (2001) conducted study on safer handling practice for nurses. The lifting and handling of people is an integral part of nursing care and has been blamed for a high incidence of back injuries to nurses. This review seeks to evaluate the growing body of research from a range of disciplines in order to establish an evidence base for the moving and handling of patients. It identifies those studies considering the impact of changes in practice on patient outcomes are lacking. A definition of safer handling practice has been derived from the literature with concomitant implications for training. Using this body of knowledge alongside studies investigating mobility of older people, the literature was used deductively to ascertain that safer handling practice has the potential to influence positively the mobility of older people. The author suggests further research to be conducted in the field of safer handling practice. 2.0 METHODS AND MATERIALS 2.1 Research design

20 In this research design analysis used is quantitative study in which it is descriptive design based on the use of survey questions to get responses from nurses in Hospital Kluang, Johor of the body mechanics of the practice among nurses in the ward itself. 2.2 Sampling and setting. This study was conducted at the Nurses where it is located in Hospital Kluang, Johor. With this study it is expected that it is going to bring benefits to all nurses working in Hospitals Setting. This study population was made up of staff nurses working in surgical and orthopedic wards. Generally, study surveyed was a population based on cross sectional study of nurses (n = 110) who worked at surgical and orthopedic ward in Hospital Kluang. Researchers did not include samples from the head nurse for the task over to the management of head nurse of the ward. In this study, researchers focused on the sample among nurses. Selected respondents were based on the level of knowledge and experience of the use of body mechanics among nurses. Selected by systemic sampling where the selection of respondents based on the list of names. 2.3 Data Collection and Instrument Data are facts, words, letters, figures, and charts or symbolically represent objects, situations, circumstances or ideas. Data obtained based on the information provided by respondents in the survey form. The questionnaire was distributed during the respondents were in the wards. Respondents were free to take the time to answer this survey but under researcher s supervision. Data analysis is an activity where all the useful information is obtained from the raw data. Data analysis involves manipulation as the arranging, selecting, combining and scheduling as well as involves the calculation of raw materials. Based on such information as evidence to indicate problem trainer. Researchers have analyzed the data using Microsoft Excel 2010 Version (32 bit). The equipment used in the form of questionnaire is divided into 3 parts, which must be completed by the respondent. It consists of 23 questions to describe the mechanics of the body, principles of body mechanics and back pain relationship with body mechanics abuse. Scoring is based on the 'Thurstone' scale, which includes 'yes' or 'no' of 16 questions.

21 Respondents were given two different statements and asked to choose. Researchers have modified the instrument in accordance with the objectives of the study focuses on the principles of body mechanics and application of body mechanics. Researchers also select free items as an instrument consists of 4 questions where respondents are asked to express an opinion without being given any choice or category. Instruments in accordance with the objectives of modifier interests and knowledge of body mechanics body mechanics related respondents.

22 3.0 DATA ANALYSIS AND RESEARCH FINDINGS i) Demographic data of respondents Table 3.1.1: Demographic data of respondents n = 110 Variable n Percentages (%) 1. Year of service < > Department General ortho (male) General ortho (female) General surgical (male) General surgical (female) Educational level Diploma Degree Master Position Junior nurses Senior nurses Nurse instructor Sister Matron Table shown about demographic data of respondents. Respondents were staff nurses from various departments. Majority of them having experiences about 1 5 years that was consider still new which was contributed 40.9 per cent whereas, 22.7 percent were the senior nurses which having experiences more than 10 years. Majority of them were working at General Surgical female ward with total 26.4 per cent. Almost of the respondents were diploma holder and finally, 47.3 per cent of the respondents were junior nurses. These demographic respondents are important to know, as this will influence their understanding on body mechanics techniques as well as the practice on it.

23 ii) Knowledge towards body mechanics techniques Table 3.1.2: Knowledge towards body mechanics techniques. n = 110 Variables Yes No n % n % 1 Does the use of body mechanics can reduce back pain? Do you agree with the statement below "Lifting patients or heavier is better to use a bed sheet from a mass hand" 3 If you do not maintain good posture while doing the procedure Do you have back pain? 4 * Maintain the proper body function * Reduce the strain / spasm. * Maintain the balance The above statement explains the importance of body mechanics practice. Do you agree? 5 Does body mechanics use continuous muscle? Object must be close to the gravity Do you agree with the statement above? 7 Does the use of continuous muscle tension and injuries cause musculoskeletal pain? The principles of body mechanics, the act of attractive may produce less friction than reject. Do you agree? 9 Are the injuries can be avoided through the body mechanics? Do you know the purpose of using body mechanics? Does heavy work activities like bending, twisting and frequent heavy lifting contribute to low back pain? 12 Improper usage of body mechanics techniques can cause spinal injury? Does attire e.g shoes play an important role to influence back pain?

24 As shown in figure 3.1.2, respondents knowledge towards body mechanics techniques, 100 per cent of respondents knew that using correct body mechanics could reduce back pain. Whilst, 68.2 per cent did not know that lifting heavier patient is better to use a bed sheet from a mass hand per cent of respondents knew that body mechanics are using continuous muscle, whereas 22.7 per cent still did not know per cent of them knew that when doing a lifting, object must be close to the gravity whereas 18.2 percent still did not know. Besides that, 100 per cent of respondents knew that continuous muscle tension and injuries could cause musculoskeletal pain. Finally, all of them knew that improper body mechanics can cause spinal injury that was 100 per cent of them.

25 iii) Body mechanics techniques practices Table 3.1.3: Body mechanics techniques practices n = 110 Variable Yes No n % n % 1 Are you asking for help from a friend if you have to lift big patient? Do you straighten your knees and bending your back when lifting an object from the floor? Are you using the principles of body mechanics during the procedure for removing a patient from bed to chair? Are you closing the legs when moving patients in the bed? Do you experience any back pain before? Do you wearing proper attire during working time? Do you know what is body mechanics all about? Do you practice body mechanics all the time during working time? Table shown about body mechanics techniques practices. 100 per cent of respondents asking help from friends if they were to lift heavy patient. Whilst, majority of them that was 92.7 per cent did straighten their knees and bending their back when lifting an object from the floor per cent of respondents experience of back pain while 68.2 did not. Finally, 68.2 per cent of respondents practice usage of body mechanics techniques all the time during working time whilst, 31.8 per cent did not.

26 Figure What are the complications related to improper use of body mechanics? %(60) %(35) %(15) 10 0 Low back pain Spinal injury Patient fall Figure showed that, 54.5 per cent of respondents knew the complication related to improper usage of body mechanics techniques is low back pain, while 31.8 percent caused spinal injury and finally 13.6 per cent can caused patient fall.

27 iv) Barrier encountered in Body mechanics What are the difficulties/barriers that you encontered in practicinbody mechanics? 13.6%(15) %(20) 68.2%(75) Lack of knowledge of the practice of body mechanics techniques Nurse do not practice proper body mechanics techniques Uncooperated patients Figure Showed that per cent respondents having difficulties in practicing body mechanics techniques as they lack of knowledge and 13.6 per cent because uncooperated patient make the situation difficult.

28 4.0 DISCUSSION AND IMPLICATIONS 4.1 Discussion and Findings This study was conducted to determine the level of understanding and knowledge also practice of nurses towards body mechanics techniques at Kluang Hospital, Johor. Respondents in this study were randomly selected from different departments of Kluang Hospital. Total of 110 respondents participated in this study. From this study, demographic data of respondents reveal that majority respondents having clinical experience within 1 5 years which was 40.9 percent and 22.7 percent was more than 10 years experience per cent were from general surgical female ward, 24.6 from general orthopedic female ward, 20.9 per cent from general orthopedic male and 19.9 per cent from general surgical male ward. Majority of respondents were diploma holder however 16.4 per cent were masters holder. These demographic details are important because it will reveal their knowledge and understanding towards the usage and important of body mechanics techniques in their clinical area of work as well as the area of work will influence the risk to have back pain due to improper use of body mechanics techniques. Even, certain area of work as well is the contributing factor to have back pain. This is supported by a study conducted by Moody J et al (1996), where 62% of nurses in the normal ward and 71% of the elderly care wards. Smith DR (2003) conducted a study on musculoskeletal disorders among female nurses in a rural Japanese hospital. Data were gathered by means of a self-reporting questionnaire from 305 female staff nurse. Lower back pain (LBP) was the most commonly reported MSD, affecting 59% of all nurses. This was followed by MSD of the shoulder (46.6%), neck (27.9%), knees (16.4%) and upper leg (11.8%). Working in the surgical department was shown to increase the risk of any MSD 2.7 times when compared to nurses in the other departments (odds ratio 2.7, 95% confidence interval , P = ). Overall, study shows that MSD are reasonably common among registered nurses who are working in surgical ward. 100 per cent of respondents knew that proper use of body mechanics techniques could prevent back pain and back injuries. According to statistical records, The Occupational Safety and Health Administration (OSHA) have calculated that nearly half of all health care workers suffer at least one work-related musculoskeletal injury during their career. More than half of all nurses (52%) complain of chronic pain and 38% of registered nurses (RNs) have suffered occupation related back injuries severe enough to require time away from work.

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