Musculoskeletal symptoms such as low back pain are serious health problems, and their prevalence is high among hospital nurses, nursing home care workers and family caregivers. Low back pain is a significant health issue for female nurses because of their generally lower physical strength compared with their male counterparts, particularly in the upper body. Tasks such as changing continence pads, adjusting a patient's posture, lifting and transferring long-term care patients, and similar physical strain are the main factors associated with low back injuries (Kyota et al, 2013; Suzuki et al, 2016). Patients’ continence pads demand frequent changes, which often requires family caregivers to bend forward. However, bending of the body's trunk by more than 20° from a stable posture increases the load on the erector spinae muscle compared with the standing position (Kyota et al, 2013). These health issues not only interrupt the continuity of care, but also diminish family caregivers’ quality of life, potentially leading to a situation in which the caregiver requires care (Suzuki et al, 2016).
Over the past few decades, significant attention has consequently been paid to the ergonomics of the daily tasks performed by nurses. However, the ergonomic design of some products has not received sufficient attention, such as absorbent continence products. The frequent use of absorbent products to manage continence creates significant problems for patients, professional caregivers and family members. The design of these products, including their overall shape, form and type, can individually or collectively make a caregiver's job more challenging. Depending on the patient's condition, position and disability, the frequent change of absorbent continence products often requires caregivers to adjust their body posture and the amount of exerted physical strength. To reduce physical strain and save time for one caregiver, two caregivers can collaborate to complete the task. Minimising this stress by making product handling easier is crucial for their development, as well as for reducing the overall burden of care (Delleman and Dul, 2005; Getliffe et al, 2007; Darragh et al, 2015).
Absorbent continence products with well-engineered designs have a complicated construction. They can absorb and retain large fluid volumes, offer better odour containment, and enhance user comfort and dignity. To date, the design of absorbent continence products has focused on the technical aspects of a pad and patient comfort.
Therefore, the present study aimed to compare various absorbent continence products by examining the time required to handle each one and the physical stress involved in product use from an ergonomic perspective.
Methods
Participants
Twenty-one non-professionals with no prior nursing experience participated in the study. The study was conducted in Germany between 4 January 2021 and 8 January 2021.
An explicit training phase was omitted; instead, pictograms shown on the packaging of continence products were provided as aids. This approach considered that non-professionals typically do not receive training in product handling. Thus, the practical conditions were simulated.
Absorbent continence products
The absorbent continence products used were the MoliCare® premium Elastic, MoliFlex (Belted) and MoliCare premium Slip.
The MoliCare premium Elastic features two wide, stretchable elastic inserts on the side panels and two wide re-closable tapes (Figure 1a). The MoliFlex is equipped with a belt, narrow elastic inserts, and two re-closable tapes (Figure 1b). The MoliCare premium Slip comprises non-woven side panels and four small re-closable tapes (Figure 1c). However, the MoliFlex is no longer available commercially.
These products are equally suitable for managing moderate-to-severe urinary and/or faecal continence in both active and immobile patients. They are designed for single use and need to be changed regularly as required. Owing to their different shapes, the handling of them varies significantly, indicating that the range of potential physical stress levels when using the products warrants further investigation.
Ergonomic study
All participants had to apply, change and remove the products from a patient in the lying and standing positions. This was followed by the main part of the test, which required each participant to apply each product, change it and remove it three times in both positions.
Prior to the evaluation, a preliminary test was conducted: this was recorded but not assessed. The duration of the test for each participant was 90–120 minutes, and all trials were recorded on video.
Measurement of handling time and stressful postures
The posture measurements assessed stress in 21 areas, which were evaluated based on their importance. By analysing the incidence and duration of stress, particularly in the hand-arm area, objective insights into the different strains caused by the three products were anticipated. Posture and movement patterns were recorded using 17 sensors and evaluated according to ergonomic guidelines and standards, with a focus on the hand-arm and back-head areas. Furthermore, evaluation of the three products was based on the number and duration of unfavourable or harmful postures, and the total time taken to complete the task. Prior to testing, the sensors were calibrated for each participant. To mark the start and end of the measurement, a specific movement that involved bending the right forearm was selected.
The collected data were processed using specialised evaluation programs that provided preliminary assessments of the postures in the 21 monitored areas. Postures were categorised into ‘green’ for good postures, ‘yellow’ for potential posture issues and ‘red’ for postures to be avoided, based on ergonomic guidelines and ISO standards for workplace posture assessment. For each body region, the absolute duration of each posture was recorded, and the percentage of time spent in the green, yellow and red zones was measured relative to the total activity duration.
Recording of hand grips
In addition to hand stress from unfavourable joint angles, the number of necessary hand grips and forces exerted when applying the continence product contribute to stress. The grip of the dominant hand was recorded by the test assistant. The non-dominant hand is used simultaneously for many substeps when changing a continence product, often serving a supporting role. Therefore, the values for the dominant hand were the most critical to record. To estimate the forces used, the maximum force for grasping and pinch grips was determined at the start of the test. After using each product, the force used for the pinch grip was estimated using a measuring instrument to evaluate the forces in relation to the initial maximum forces.
Subjective assessment of continence products
After each complete cycle with the product (standing and lying positions were measured separately), the participants were surveyed using a questionnaire. Respondents rated the products based on speed, back friendliness, simplicity of application and the helpfulness of the pictograms on the product's package for application. The rating for each category ranged from 0 to 3, with 0 being the worst and 3 being the best product.
Data analysis
The dependent samples t test was used for data analysis.
Results
Time required for product handling
The results for the lying down position differed significantly from those for the standing position. A comparison of the work cycles (applying, changing and removing the incontinence product three times) for both positions found that for all three products the standing position had the shortest mean time compared with the lying position. The time difference between the two positions was significantly longer for the MoliFlex (Belted) and was the shortest in the case of MoliCare premium Slip product. Furthermore, the MoliCare premium Elastic had the shortest mean work cycle time in both the lying down (396 s) and the standing (315 s) positions. In the case of the other two products, the work cycles for both positions were longer: however, the MoliFlex (Belted) was faster than the MoliCare premium Slip in the standing position (335 s versus 378 s), but the reverse was the case for the lying down position (463 s versus 435 s) (Figure 2).
In addition to the results outlined above, the measurements recorded during the third change are discussed further below. At the third change, the trend remained consistent. The MoliCare premium Elastic remained the quickest product to change in both the lying down (93 s) and the standing (74 s) positions; the MoliFlex (Belted) required the longest time for change in the lying down position (108 s) and the MoliCare premium Slip took the longest time to change in the standing position (90 s).
Evaluation of stressful postures
Analysis of the total time spent while working in each position by participants in stressful postures (back-head and hand-arm) that are the most harmful makes evident the differences between the products. The shortest time spent in highly stressful postures across all body regions was recorded for the MoliCare premium Elastic. Although participants spent a longer time in stressful postures when applying the MoliFlex (Belted), it required less time than for the MoliCare premium Slip. In the case of the latter, participants spent the longest time in highly stressful postures. The high values for stressful postures were due to the simultaneous occurrence of multiple stresses, with the mean times illustrated in Figure 4.
Comparison of the time spent in stressful postures with the time required for the third change (Figure 4 versus Figure 3) showed that postural stress increased disproportionately with working time. For example, although the duration of the third change was nearly the same for MoliCare premium Elastic and MoliCare premium Slip in the lying down position, there significantly higher postural stress in the case of the Slip. This indicates that the additional strain was due mainly to the product and its handling, rather than the longer working time.
Stressful hand and arm postures
Focusing specifically on hand-arm stress, there was a clear trend in the lying down and standing positions. Consistently least stress was observed in both positions when applying the MoliCare premium Elastic product, with the MoliFlex (Belted) recording the second least stress and the MoliCare premium Slip the greatest stress. With the patient in the standing position, MoliCare premium Slip recorded a significantly higher load compared with the other two products. In the lying down position the MoliCare premium Elastic performed best, indicating that the other two products were less effective in reducing hand-arm stress (Figure 5).
Stressful back and head postures
Figure 6 shows that the MoliCare premium Elastic and MoliFlex (Belted) products resulted in fewer stressful back and head postures in both the lying down and standing positions compared with the MoliCare premium Slip; the latter recorded a significantly longer mean time spent in these stressful postures.
Number of hand grips
Figure 7 shows the number of hand grips recorded over the three changes for each product. Fewer hand grips were required when working in a standing position for all three – because the patient did not need to move, the carer had accessibility at the front and the back.
Handling of the MoliCare premium Elastic involved the least frequent hand grips in both the lying down and standing positions, followed by MoliFlex (Belted) and MoliCare premium Slip.
Following each session, during which participants applied, changed and removed a product three times, they were asked to evaluate the product against a number of characteristics. The rating options for each ranged from 0 to 3, with 0 indicating the worst and 3 the best product.
A comparison of the evaluations for the three products, as set out in Table 1, show insignificant differences in participants’ ratings for each.
| MoliCare premium Elastic (lying down position) | MoliCare premium Elastic (standing position) | MoliFlex (Belted) (lying down position) | MoliFlex (Belted) (standing position) | MoliCare premium Slip (lying down position) | MoliCare premium Slip (standing position) | |
|---|---|---|---|---|---|---|
| Speed | 2.40 | 2.40 | 2.20 | 2.80 | 2.30 | 2.40 |
| Back friendliness | 2.30 | 2.40 | 2.10 | 2.50 | 2.10 | 2.40 |
| Simplicity | 2.20 | 2.20 | 2.10 | 2.60 | 2.40 | 2.10 |
| Helpfulness of the pictogram | 2.40 | 2.40 | 1.60 | 1.90 | 2.50 | 2.40 |
NB Each characteristic was rated on a scale of 0 to 3, with 0 being the worst and 3 the best
From the participants’ perspective, it was faster to apply a product with the patient in the standing position than doing so with the patient in a lying position. Furthermore, the MoliFlex (Belted) was rated significantly better when applied in the standing position. The standing position was generally considered more back friendly, and the Belted product achieved the highest satisfaction rating for back support. The participants found the MoliFlex (Belted) easier to apply in the standing position compared with the other two products.
However, the MoliFlex (Belted) received the worst rating regarding the helpfulness of the pictogram, indicating that it was particularly challenging to understand how it should be applied, and more so with the patient in the lying down position.
In the objective evaluation, the MoliCare premium Elastic outperformed the other two products. However, in the subjective evaluation, in which participants rated the different characteristic, the MoliFlex (Belted) product received higher scores. The subjective evaluation was conducted at the end of the test, so it is reasonable to assume that participants may not have answered the questions using their full concentration, eg due to tiredness, which could have affected the results.
Discussion
The ability to control the bowel and bladder is associated with maintaining privacy, self-esteem and dignity. Patients with continence problems often require assistance from family members, which affects the emotional, physical and social wellbeing of both patients and family caregivers. This assistance includes frequent help with toileting or pad changes throughout the day and night, often leaving family caregivers with limited personal time (Tseng et al, 2015).
Changing pads can also pose a physical health risk to family caregivers, particularly to the lower back. The posture they adopt during pad changes depends on the patient's position and involves co-ordinated movements of the hands, arms, head and back to remove the old pad and apply a new one. Caring for patients can sometimes cause family caregivers to sacrifice their wellbeing, particularly when unexpected situations arise.
In the present study, non-professionals were asked to apply three different absorbent continence products with patients in the lying and standing positions to evaluate the time needed to handle each product and the physical stresses involved from an ergonomic perspective. The results showed that all participants were able to use the three products independently without assistance, relying solely on the packaging instructions. After the single trial run of applying and removing the products, they were able to carry out the test without any anticipated errors or need for assistance.
The design of the absorbent continence product and the patient's position significantly affected work cycle time and stressful postures for the participant. For all the three products, the mean work cycle time was shorter in the standing position, which involved less stressful back postures and required fewer strenuous movements. This is likely to be the result of enhanced visibility and better viewing angles, with the participant required to bend and rotate the trunk less often, thereby placing the back in a better posture.
A review of the time required to handle the products in the standing position revealed that the MoliCare premium Elastic required the shortest time for application, change and removal. The next shortest time was required for the MoliFlex (Belted), with the MoliCare premium Slip requiring the longest time. The differences were largely significant, and they may prove useful in the daily use of the continence products, potentially saving a minute or more per cycle.
Although the MoliCare premium Elastic required the shortest time to apply and change in the lying position, the differences between MoliFlex (Belted) and MoliCare premium Slip were smaller and insignificant. In the lying down position, the MoliCare premium Slip required less time to handle than MoliFlex (Belted).
The difference in work cycle time and unfavourable postures between MoliCare premium Elastic and the other two designs was likely due to the easier fixation process using the two re-closable tapes in the MoliCare premium Elastic product. In contrast, securing the MoliFlex (Belted) and MoliCare premium Slip products often requires additional adjustments, which prolonged the periods of flexion, rotation and generally harmful postures.
MoliCare premium Elastic had the shortest exposure time to highly stressful postures in all body regions. This is crucial for practical use, as the time required for the work cycle is not always the most critical factor in the non-professional sector. Instead, physical stress has a greater impact, especially when there is a lack of expertise and training in handling the absorbent products.
Conclusion
The design of absorbent continence products plays an important role for patients dealing with continence issues. Innovative and high-performance absorbent products have sophisticated constructions that include advanced materials and technologies, and their manufacture requires state-of-the-art production facilities. This leads to a product with high absorption capacity and wicking properties, which at the same time prevents urine leakage and odour.
The study results indicate that product design is crucial for family caregivers, because it can simplify product changes, save time and enhance lower back posture. Among the three products tested in this study, the MoliCare premium Elastic consistently had the shortest handling times and required the least physically stressful postures, particularly when applied in the standing position. Furthermore, efficiency in handling and changing patients enables family caregivers to invest time in other aspects of care, thereby enhancing the quality of life of both the patient and themselves.