A nurse is assisting with transferring a client from the bed to a wheelchair

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1 Introduction

In the United States, it is reported that 2.5 million people develop pressure ulcer annually, which requires 11 billion US dollars in expense per year, causing an increase in medical care cost [1]. In Japan, the estimated percentage of pressure ulcer incidents is 1.5% in the general ward, and 5.1% in the recuperation ward [2]. It is reported that the medical expense used for the treatment of pressure ulcer and wound dressing material for leg ulcers is 4.4 billion and 43 million JPY. “Never Events” are if the stages III–IV of “hospital-acquired pressure ulcer” occurs after being hospitalized. In Japan where the elderly are more prone to illness, the preventive method for pressure ulcer becomes the important issue from the standpoint of medical safety and the health care economy.

Considering this background, repositioning and early mobilization is recommended in the Clinical Practice Guideline for Prevention and Treatment of Pressure Ulcer provided by National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance [3]. It mentions how to reposition the individual in a way to relieve and disperse the body pressure and use a split leg sling mechanical lift when available to transfer an individual into a wheelchair or bedside chair when the individual needs total assistance to transfer. Remove the sling immediately after transfer. Repositioning and early mobilization is an important nursing technique for the pressure ulcer prevention and management policy. Us Wound, Ostomy Continence Nurses have been providing the education for the people assigned in professional occupations. But, the educational system for this field has not been established in the undergraduate education, nor can many previous study cases be found.

In this study, we conducted the experiment on nursing undergraduate students and Wound, Ostomy Continence Nurses (WOCN). The purpose of this study is examining the nursing technique when repositioning a patient by focusing on the body pressure distribution and explicating the tacit knowledge that underlie the nursing technique of skilled workers. We assigned 2 test subjects consisting of 1 nursing undergraduate students who have finished the clinical practice, and 1 WOCN nurse who has 27 years working experience at the general hospital. We classified nursing student as non-experts, and 1 WOCN as an expert. For an experimental environment, a urethane foam mattress was put on the medical-use bed, and allocated one simulated patient on the bed. The measurement was conducted in the following Transferring from the bed to the wheelchair. The three-dimensional motion analysis was conducted using the MAC 3DSYSTEM (Motion Analysis) with a sampling rate of 100 Hz, and the analysis software was EvaRT, ver 5.0.4.

ERGOCHECK (ABW Co., Ltd.) was used for body pressure measurement. After treating the data of the human pressure measurement by PC, we depicted the pressure distribution between the human body and the mattress for analysis. Moreover, the questionnaire survey regarding fatigue was conducted on the 1 subject before and after the movement measurement experience. We also digitalized the transferring technique used when getting a patient out of bed.

2 Background

2.1 Conditions Around the Occurrence of Low Back Pain Among Nurses

Occupational low back pain can be divided into two categories: accidental, which is caused by injuries sustained at work, and non-accidental, caused by work that involves handling heavy loads or excess strain on the lumbar spine. Low back pain caused by assisting patients during a transfer is classified as the non-accidental category. The rate of low back pain occurrence among nurses is 43% in the U.K. [4], 40–50% in the U.S. [5], 69.7% in Taiwan [6], and 60% in Japan [7]. Japan marked higher occurrence rate comparing other countries. Low back pain occurrence rates in the U.K. are lower than other countries due to initiatives by the National Back Pain Association to raise greater awareness of the issue [8]. Its 1981 publication, the Guide to the Handling of Patients, recommends education, training and the use of assisting devices to combat low back pain among the U.K. nurses. In addition to the Health and Safety Executive, the association established the Manual Handling Operations Regulations [9] that set a load-handling limit of 25 kg per person. This accelerated the installation of mechanical lifts and continues to reduce low back pain for the nurses. In 2003, the Occupational Safety and Health Administration established the Guidelines for Nursing Homes, which recommends the use of nursing care devices and specifies the number of staff that must be present when performing a transfer. According to the National Institute of Occupational Safety and Health, the preventative measures have led to a notable reduction in the occurrence of musculoskeletal injuries that led to reduced working hours, financial compensation and time taken off from work [10].

According to our own Ministry of Health, Labour and Welfare, low back pain that requires rest of more than 4 days at a welfare facility accounts for about 19% of occupational illnesses, and has increased 2.7-fold in 10 years. Within those numbers, 50–70% of nurses reportedly experience low back pain [11]. The conditions in Japan are serious. However, there is no evidence available from randomised controlled trials for the effectiveness of manual material handling (MMH) advice and training or MMH assistive devices for treating back pain [12].

Among the nurses who report low back pain, 47.8% are male, 61.5% are female, with the number of complaints peaking at women in their 30s, then declining from 40s onward, though the reason for this remains unclear [7]. We couldn’t find any thesis pertaining to low back pain, gender and age targeting nurses, but according to the ministry [13], the number of complaints rise in accordance with age.

2.2 Motions that Cause Low Back Pain and Its Mechanism

Transfers account for 65.1% of the occurrence of non-accidental low back pain at welfare facilities, especially when transferring from bed to wheelchair, but also during bathing assistance (23.3%), helping with elimination (12.7%). Furthermore, the highest incidence of low back pain (47.8%) came when the caregiver was facing the patient and the burden of supporting the patient is on the back of the care giver [14]. Additionally, when assisting with wheelchair transfer, the embracing motion has been identified as the cause of low back pain [15, 16].

Low back pain is triggered by the loss of lumbar support due to degeneration in the lumbar spinal column. As a result, the nervous system that runs through the spinal column, or the nerve endings present in each structure that makes up the spinal column are mechanically stimulated, which in turn triggers inflammation in the nervous system or areas around it and causes the symptoms of back pain. The intervertebral joints, the paraspinal muscles and the sensory receptors distributed to the posterior elements of the lumbar region are particularly sensitive and contribute to nonspecific acute low back pain caused by movements and posture [17]. Wheelchair transfers by nurses activate the shoulder joints, elbow joints and knee joints. The shoulder joints are innervated from the cervical spine (C4–C8); the elbows, from C4 to Thoracic spine 4; the knee joints, from L5–L7. Psychological stress has been clearly linked to the onset of low back pain, chronic or otherwise [18]. However, we found no studies that demonstrate the effectiveness of early prevention of fatigue and psychological stress on low back pain among nurses.

2.3 Interface Pressure and Pressure Ulcers When Seated in a Wheelchair

A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear. A number of contributing or confounding factors are also associated with pressure ulcers; the significance of these factors is yet to be elucidated. Transferring to a wheelchairs is recommended in Use variable-position seating (tilt-in-space, recline, and standing) in manual or power wheelchairs to redistribute load off of the seat surface. The Clinical Practice Guideline for Prevention and Treatment of Pressure Ulcer provided by National pressure ulcer advisory panel, European pressure ulcer advisory panel and pan pacific pressure injury alliance.

Especially patients who use wheelchairs run a very high risk for developing pressure ulcers, and 27% of the 3,361 with a spinal cord injury reportedly have Stage II (partial thickness skin loss) pressure ulcer [19, 20].

According to Landis [21], arterial capillary pressure is around 26–32 mmHg, and an additional pressure of 70–100 mmHg for more than 2 h has been shown to cause structural damage. Moreover, measuring the pressure distribution in the sacral region of bedridden elderly patients has shown that pressure ulcers develop at 40–50 mmHg [22]. Applying pressure of more than 50 mmHg during a position change constricts the capillaries and cause structural damage. Therefore, this change from a sitting position to a lying position is thought to improve wound healing.

Due to the above, it is believed that adequate amounts of pressure redistribution when seated during a wheelchair transfer can help prevent pressure ulcers. However, we were not able to find any studies of seat pressure distribution comparing nursing students to experts. We believe that measuring the seat surface of the wheelchair will reveal what effect differences in transfer behavior between a nursing student and an expert will have on the body pressure of the simulated patient (SP).

3 Previous Research on Transfer Assistance by Nursing Students

Observing a Japanese nursing student help a patient transition from a supine position in bed to a portable toilet, one study concluded that the most stressful actions on the lumbar spine were standing up, twisting and sitting down. Movements related to upper body elevation places the most stress on the lumbar spine [23].

Most adults flex their lumbar spine to assist people out of bed. The expert, on the other hand, does not and keeps the lumbar region largely extended [24]. Furthermore, the good movements of the expert can be adopted by regular adults. Low back pain contributes significantly to nurses quitting their job and needs to be addressed in order to secure the labor force of nurses [25]. However, with regards to low back pain prevention, there are no lessons on techniques or lectures about position changing in basic nursing education at universities. There are also no educational programs structured around low back pain. We need to raise an awareness about keeping our nurses in good health, and education for preventing low back pain so that we can also stop losing our nurses from back injury.

4 Design Study

The design of this study is research experiment, using a motion capture system to analyze wheelchair transfer motions. The purpose of this research was to study the motions of the non-expert (nursing student) and the expert (WOCN), looking specifically at interface pressure in the nursing techniques they employ in changing body positions, and turning what is tacit knowledge into one that’s more explicit. We evaluated the wheelchair transfer motions done by the expert and non-expert, and difference in the interface pressure dispersion of the simulated patient. The research question for this study was what the differences are in the wheelchair transfer motions between the expert and the non-expert, and how those differences would impact low back pain and the patient’s interface pressure.

In this study, the expert has been established as a highly proficient nurse who possesses a lot of experience, an intuitive grasp of the clinical situation and can accurately connect an issue with a prescription without second-guessing him or herself. Further more, the non-expert (nursing expert) has been defined as a novice. Novice is defined as beginner with no experience, but who were taught general rules to help perform tasks [26].

5 Motion Analysis of Wheelchair Transfer Techniques that Observe the Interface Pressure of the Nursing Student

5.1 Participants

We assigned two subjects for this study. One subject was a nursing student who had studied basic nursing unit and received basic nursing clinical practice training at a university school of nursing science. And the other was a nurse who worked at a 580-unit hospital specializing in spinal cord injuries and rehabilitation, and with 27 years of experience as a wound ostomy continence nurse (WOCN) educated in the activities covered by this research. The student was the non-expert, and the WOCN was the expert. The SP was a healthy adult (Table 1).

Table 1. Attributions of participants

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5.2 Procedure and Setting

The movements to be studied were the transfer from bed to wheelchair. We used a height-adjustable bed that allowed the SP to sit in the center of the side frame of the bed with the soles of his feet touching the floor. The scenario was that the patient is unable to stand on his own and requires full nursing care. The participants were briefed on the conditions of the SP and were asked to transfer him from the bed to the wheelchair. As for the positions of the bed and the wheelchair, the latter was placed facing 30° toward the bed, with a slight adjustment to make the transition of the SP a little easier. As for the wheelchair transfer motions and interface pressure, we measured movements of each participant twice per single motion. We had a chair ready for the participants to rest if they got tired.

In measuring the participants’ motions and interface pressure, we used a video to record all the movements of the patient’s body during the transfer, from the slight shifts to bigger lifting movements. Before and after the wheelchair transfer, we asked the participants to fill out a questionnaire pertaining to fatigued body parts and symptoms they are aware of, using the Assessment tool for fatigue [27].

This research received approval by Osaka Industrial University’s Research Ethics Committee (Number 011). We briefed the participants beforehand on the outline of the research on paper and obtained their consent in writing. We informed them that they could stop any time they felt tired to get some rest.

5.3 Classification of the Movements from Bed to Wheelchair

The bed-to-wheelchair motion was categorized into four phases. The first is “assisting from sitting up to standing up,” which involved the point at which the assistance began, the point at which the participant’s hips were at the lowest position, and the point at which the patient completes standing. The second is “assisting with direction change”. And the third is “assisting to sit in the wheelchair,” which covers the movement from the lowest point of the participant’s hips while helping with sitting to the end of the seated position of the participant. And finally, “seat readjustment assistance.” These motions were analyzed, and each participant’s phase was contrasted against the other (Table 2).

Table 2. Motion categories of transfer assistance motion from bed to wheelchair

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5.4 Measurement Methods

Using Motion Capture to Analyze the Wheelchair Transfers of the Expert and Non-expert

The reflector markers were attached to the body surface and movement during transfer assistance were recorded by five cameras to record 3-dimensional footage. Sixteen reflector markers were attached to the subject as shown in Fig. 1: The model had attachments on the head (top, right, left), neck (cervical nerve 7), shoulder, top, bottom (thoracic nerve 12), middle (lumbar nerve 5), trochanter major (TRO), hip, elbow, wrist, thigh, knee, shin, ankle and toe.

Fig. 1.

The attached locations of the reflector markers

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For this research, we didn’t attach reflective markers to the abdominal area since the patient would block the view. Instead, reflective markers were attached to the back of the participants to achieve a 3-dimensional analysis. The participants’ movements that were tracked were assisting the patient from a seated position to the wheelchair. We used a MAC 3D System (motion analysis), sampling rate 100 Hz, creating stick figures to perform a three-dimensional motion analysis. The software was EvaRT Ver. 5.0.4 (motion analysis). We used it to calculate the participant’s cervical spine angle, knee joint angle, lumbar flexion angle per motion, as well as the time it took for each movement. We also measured the inter-wrist and inter-ankle distances.

The model had attachments on the head (top, right, left), neck (cervical nerve 7), shoulder, top, bottom (thoracic nerve 12), middle (lumbar nerve 5), trochanter major (TRO), hip, elbow, wrist, thigh, knee, shin, ankle and toe.

Measurement of Interface Pressure of a Simulated Patient at Time of Wheelchair Transfer

One simulated patient lay on a 9 cm-thick polyurethane mattress on a bed used for medical treatment. The interface pressure measurement sheet was set on the wheel-chair to measure the interface pressure.

ABW GmbH, ERGOCHECK was used for the interface pressure measurement. ERGOCHECK applies 712 sensors to the sheets. Each sensor detects pressure between human body and mattress per 5–10 cm square. It can serve as a measuring instrument to detect interface pressure. The measurements are classified into two categories: the seated surface after wheelchair transfer, and the seated surface after the seat is readjusted, comparing the expert and non-expert. Once the interface pressure data is processed on a computer, the distribution of pressure on the body and the mattress is drawn out and analyzed, with the expert and non-expert being compared. The mean and standard deviation are calculated by looking at the average pressure and maximum pressure applied by both the expert and the non-expert.

Questionnaire Survey on Fatigue

The assessment tool for fatigue totals scores in five categories – drowsiness, instability, discomfort, weakness, and blurring vision – to benchmark fatigue levels. It also tracks where the fatigue manifests in the body and can obtain the total score of fatigue degree of each body part. It estimates fatigue and pain as well as back pain. Statistics from the fatigue survey were used.

5.5 Results

Time Elapsed in the Four Aspects of the Wheelchair Transfer for Both Expert and Non-expert

The expert spends 68 s in the wheelchair transfer. The breakdown is 18 s for the expert to assist from sitting to standing, 24 s for a direction change, 16 s to assist to a seated position, and 10 s to readjust the seated position. The changing of direction took the most time. The non-expert spends 32 s in the wheelchair transfer. The breakdown is 11 s from sitting to standing, 2 s for the change of direction, 9 s to assist to a seated position, and 10 s to readjust the seated position. Going from sitting to standing took the most time.

The Joint Angles, the Distance Between the Wrists and Between the Ankles in the Motions of the Four Aspects of the Wheelchair Transfer

Please refer to Figs. 2 and 3, for information on the angles of the cervical spine, lumbar, knee joint and elbow joint for the expert and non-expert.

Fig. 2.

The joint angle of expert

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Fig. 3.

The joint angle of non-expert

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Assistance From Sitting To Standing

When the expert makes contact with the SP, the body angles of the expert were as follows: cervical spine, 155.2°; lumbar, 50.5°; knee joint, 144.4°; elbow joint, 132.7°. The wrists were 50.0 cm apart, and the ankles were 22.8 cm apart.

When standing, the expert’s lower back at its lowest point was: cervical spine, 171.6°; lumbar, 60.9°; knee joint, 140.8°; elbow joint, 134.2°. The wrists were 70.7 cm apart, and the ankles were 41.7 cm apart.

The body angles of the expert after the SP is standing were 164.8° for the cervical spine; 60.3° for the lumbar, 133.6° for the elbow joints. The wrists were 43.3 cm apart, and the ankles were 46.8 cm apart.

When the non-expert makes contact with the SP, his body angles were as follows: cervical spine, 151.2°; lumbar, 93.0°; knee joint, 160.9°; elbow joint, 161.2°. The wrists were 24.2 cm apart, and the ankles were 52.5 cm apart.

When standing, the non-expert’s lower back at its lowest point was: cervical spine, 147.2°; lumbar, 56.1°; knee joint, 144.1°; elbow joint, 149.2°. The wrists were 24.6 cm apart, and the ankles were 52.3 cm apart.

The body angles of the non-expert when the SP is standing were 148.1° for the cervical spine, 68.7° for the lumbar, 145.6° for the knee joint, 163.1° for the elbow joint. The wrists were 22.6 cm apart, and the ankles were 50.3 cm apart.

Direction Change Assistance

The body angles of the expert at the start of the direction change were: cervical spine, 175.7°; lumbar, 56.6°; knee joint, 150.3°; elbow joint, 100.2°. The wrists were 43.0 cm apart, and the ankles were 42.5 cm apart. The body angles of the non-expert at the start of the direction change were: cervical spine, 148.1°; lumbar, 69.0°; knee joint, 154.3°; elbow joint, 128.0°. The wrists were 22.9 cm apart, and the ankles were 49.0 cm apart.

Wheelchair Seating Assistance

While seating the SP, the body angles of the expert were: cervical spine, 167.9°; lumbar, 77.0°; knee joint, 127.1°; elbow joint, 104.3°. The wrists were 50.0 cm apart, and the ankles were 42.5 cm apart. After seating the SP, the cervical spine was 160.1°, the lumbar was 81.1°, the knee joint was 130.6°, and the elbow joint was 99.0°. As far as the distance during the seating, the wrists were 43.0 cm apart, and the ankles were 42.5 cm apart. Afterwards, the wrists were 34.2 cm apart, and the ankles were 34.3 cm apart.

While seating the SP, the body angles of the non-expert were: cervical spine, 161.6°; lumbar, 53.9°; knee joint, 32.5°; elbow joint, 127.1°. The wrists were 33.5 cm apart, and the ankles were 61.6 cm apart. After the seating, the cervical spine was 152.6°, the lumbar was 55.3°, the knee joint was 120.9°, the elbow joint was 123.2°. As for the distance, the wrists were 39.5 cm apart, and the ankles were 62.0 cm apart.

Seat Adjustment Assistance

After completing the seat readjustment, the body angles of the expert were: cervical spine, 167.2°; lumbar, 75.6°; knee joint 141.6°; elbow joint 141.0°. The wrists were 51.1 cm apart, and the ankles were 49.7 cm apart. The expert talked to the patient throughout all the activities, confirming with the patient through each movement.

After completing the seat readjustment, the body angles of the non-expert were: cervical spine, 152.7°; lumbar, 55.3°; knee joint, 143.5°; elbow joint, 140.0°. The wrists were 49.0 cm, and the ankles were 41.9 cm apart. The non-expert did not talk at all during the activities.

The difference in the angle of the cervical spine and Head top between the expert and non-expert when doing wheelchair transfers are show below (Figs. 4 and 5).

Fig. 4.

Comparisons of the angle of expert and non-expert’s cervical spine

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Fig. 5.

Comparisons of the head top of expert and non-expert’s cervical spine

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The Joint Angles, the Distance Between the Wrists and Between the Ankles in the Motions of the Four Aspects of the Wheelchair Transfer

The average angle of the joints during the four phases of activity was researched (Fig. 6). The average angle for the cervical spine was 161.1 ± 6.9 without flexion and some straight extension. In contrast, the non-expert was flexion and carried the burden on his cervical spine. Fatigue was reported in the survey in his trapezius and musculus sternocleidomastoideus. The average anglke of the lumbar was 66.0 ± 11.

Fig. 6.

Average joint angle comparisons for all activities

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The knee joint angle was 139.2 ± 7.9°. The elbow joint was 120.7 ± 18.6°. The distance of the ankles was 48.9 ± 11.3 cm, whiole the wrists were 40.0 ± 9.0 cm apart.

The angle of the non-expert’s cervical spine was 151.6 ± 4.9°. The average for the lumbar was 65.4 ± 13.6°. The knee joint angle was 144.3 ± 11.2°. The elbow joint angle was 141.7 ± 16.5°. The wrists were 48.8 ± 12.9 cm apart, while the ankles were 34.9 ± 12.4 cm apart.

The Interface Pressure of the Simulated Patient When Seated in a Wheelchair

The area of contact on the seat surface was 1300.0 cm2 (Table 3, Fig. 7) after the expert assisted the wheelchair transfer. The maximum contact pressure was 92.8 mmHg, and the average was 27.6 mmHg. After readjusting the seat, the area was 2370 cm2. Maximum contact pressure was 70.5 mmHg, and the average was 14.6 mmHg.

Table 3. Area of contact on seat surface after wheelchair transfer

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Fig. 7.

Distribution of body pressure on seat surface after wheelchair transfer

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The area of contact on the seat surface was 990.0 cm2 after the non-expert assisted the wheelchair transfer. The maximum contact pressure was 95.0 mmHg, and the average was 29.00 mmHg. After readjusting the seat, the area was 2850 cm2. Maximum contact pressure was 63.9 mmHg, and the average was 12.2 mmHg.

The Shifts in the Fatigue Before and After the Wheelchair Transfer as Reported by the Expert and Non-expert

We conducted a survey using the assessment tool for fatigue provided by Working Group for Occupational Fatigue. Before conducting wheelchair transfer activities, the expert reported fatigue and weakness in two places, including her trapezius and left deltoid. After the activity, she reported feeling slight fatigue in her left deltoid and triceps, but the fatigue in her trapezius and stiffness in her shoulders had disappeared (Fig. 8).

Fig. 8.

Change in the expert’s fatigue

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Before conducting wheelchair transfer activities, the non-expert reported experiencing slight fatigue in seven places, including the both trapezius, the both psoas major, the right deltoid and the both musculus sternocleidomastoideus. After the activities, he reported feeling quite a bit of fatigue in nine places, including the both trapezius, both psoas major, right deltoid, the both musculus sternocleidomastoideus, and the both orbicularis oculi muscle.

The expert’s self-reported symptoms, including drowsiness and discomfort, declined from seven before the activity to five afterwards. Unpleasant feelings dropped from eight to six. Blurriness went from ten incidents to seven, and weakness went from six to five.

The non-expert’s self-reported symptoms included drowsiness at twelve points before the activities. That was unchanged after the activities. Discomfort and blurriness both stayed unchanged at six, and pain in the eyes was reported. Unpleasant feelings decreased from nine to five. Weakness rose from five to seven. Stiff shoulders and sore knees were reported (Fig. 9).

Fig. 9.

Change in non-expert’s fatigue

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6 Discussion and Conclusions

6.1 Analyzing Aspects of the Expert and Non-expert’s Movements During Wheelchair Transfer

Analysis of the four aspects of the wheelchair transfer conducted by experts and non-experts, measuring the expert’s timing, angle of the cervical spine, lumbar spine, knee joint, and the distance between wrists and ankles.

Comparing the Motions of the Expert and Non-expert When Assisting a Patient from a Seated to Standing Position

Looking at the time required, the expert took 2.3 times longer than the non-expert. It takes longer because the expert talks with the SP and takes care to note the person’s physical abilities while making the transfer. Also, the non-expert put his cervical spine into more anteflexion position than the expert when he touched the SP’s body. The non-expert is 11 cm taller than the SP, so he bends into an anteflexion position to make up for the height difference. Also, it is thought that the non-expert doesn’t flex his knees and lumbar spine as much as the expert and hasn’t learned good body mechanics that suggesting to bend knees to lower the hip position.

The width of the expert’s ankles when standing up is 22.8 cm. The width of the non-expert is 24.2 cm, making the width of their feet and support base about the same. The expert angles her back less than the non-expert. The expert flexes her knees more than the non-expert. The expert’s position is stable and her center of gravity is low, reducing the stress on her back.

When the lower back of the non-expert is bent the least, the angle of his cervical spine is in a more anteflexion position than when he started, creating fatigue in the trapezius and the musculus sternocleidomastoideus stretching from left to right. The scores rose for stiff shoulders and a feeling of heaviness compared to before the activity. At the end of standing up, the expert kept her lumbar spine in a flexion position more than the non-expert did.

Comparing the Motions of the Expert and Non-expert When Assisting a Patient in Changing Directions

The expert assisted in changing the patient’s direction for 24 s. Through experience, she knows that changing directions can result in imbalance and create unease in the patient, so it is thought that she takes her time. The expert’s cervical spine is at a 175.7-degree angle when changing directions; the lumbar is at 97.4°. The extension of the cervical spine and the lumbar is clear. The difference in height between the patient and the expert was 9 cm. Since she will be supporting the patient around the chest area, the expert’s knees were in a flexion position of 139.6°, lowering the center of gravity.

The knee joint of the non-expert was at a 154.3-degree angle when assisting in the change of direction. Because it was 132.5° and in a flexion position in a sitting posture, it was thought that the pelvis wasn’t at a steady height, affecting the stability when making the change in directions. When the non-expert changed directions, his cervical spine and lumbar were in an anteflexion position, and the knees were hardly flexion at all, putting the burden on the L5–L7.

Comparing the Motions of the Expert and Non-expert When Assisting a Patient into a Seated Position on the Wheelchair

When an expert assists a patient into a seated position, the elbow joint is in a 99-degree flexion position, and the wrists are 34.2 cm apart. It is thought that the distance between them is close because the expert will grab the patient’s belt and pull his body up.

The non-expert’s elbow joint is at a 123.2-degree angle, and the wrists are 39.5 cm apart. The distance is greater when the non-expert puts the patient in a seated position. Also, as when changing directions, the non-expert’s cervical spine is in an anteflexion position, and fatigue is thought to appear in the trapezius and musculus sternocleidomastoideus stretching from left to right.

Comparing the Motions of the Expert and Non-expert When Assisting a Patient in Seat Readjustment

The angle of the elbow joint and knee joint of the expert when assisting in seat readjustment are at about the same angles. Also, as when changing directions, the non-expert’s cervical spine is in an anteflexion position, and fatigue is thought to appear in the trapezius and musculus sternocleidomastoideus stretching from left to right.

Comparing the Average Joint Angles of the Expert and Non-expert When Performing a Wheelchair Transfer

The expert extends her cervical spine before standing up. Once standing, she tilts slightly forward. This is thought to be because she checks on the stability of the movement by confirming the footing of the SP. Also, she confirms the sitting position and puts the cervical spine in an anteflexion position when sitting.

The non-expert has his cervical spine in an anteflexion position through all the movements. In contrast, the non-expert has a daily appearance of fatigue because he feels it in seven places, including the both trapezius, the both psoas major muscle, the right deltoids, and the both musculus sternocleidomastoideus. After the activity, subjective symptoms include stiff shoulders, a strong feeling of fatigue, and tired eyes. Subjective symptoms and fatigue blend together after the activities. It is thought that keeping the cervical spine in an anteflexion position means the body will bear the brunt of the load.

With wheelchair transfers, the expert keeps her elbow joints more flexion than the non-expert and her wrists farther apart. When the SP is bigger than the nurse, and the nurse can’t hold the patient around his lower back, a belt is used to raise him up, which causes the burden on the triceps and the elbow joint. After the activity, feeling fatigue in the left triceps is thought to be because she used her arms for lifting with a belt.

An aid is necessary, but because curriculum concerning the use of aid at nursing schools and medical facilities has not progressed, it’s necessary to build this into the educational program to enlighten practitioners.

6.2 The Effect of the Wheelchair Transfer in the Interface Pressure of the Simulated Patient When Seated in the Wheelchair

The interface pressure of the simulated patient when assisted by the expert, the area of contact is wide and the seat is deep. With non-experts, the area of contact is narrow and the seat is shallow. Also, referring to the video recording, the seat remains shallow when assisted by the non-expert and he is unable to steady the patient, having no consciousness of the depth of the seat surface.

The width of the expert’s feet during a change of direction and while sitting is 42.5 cm, but the width of the non-expert’s feet changes from 49.0 cm during a change of direction to 61.6 cm and 12.6 cm while seating a patient, and flexion is rarely seen, leading to unsteady support. This is thought to increase the risk of the patient falling. By giving feedback to the non-expert using three-dimensional movement analysis and interface pressure when seating, it is possible to actively educate them about wheelchair transfers.

Furthermore, the non-expert applies more body pressure on the seat after transfer, so it is necessary to explain that wider support of the patient’s buttocks will help him sit deeply. With this action, readjusting the seat position becomes unnecessary, and the frequency with which the lumbar and cervical spine are in a flexion position can be reduced.

6.3 Challenge Topics for the Non-expert on Wheelchair Transfers

The expert used in this research is a middle-aged woman experiencing typical aging issues such as the decline in estrogen, cardiopulmonary functions and endurance. However, the expert experienced less fatigue and fewer self-described symptoms than the much younger male non-expert when it came to the activities. It’s thought that this is because the expert’s spine was not anteflexion and the distance between her knees and ankles was uniform, giving her a stable base. The non-expert needs to learn about the techniques for using his cervical spine, knee joints and feet correctly. As there was just one expert and non-expert, we can’t make broad conclusions. Our further challenge is to proceed more movement analysis for utilizing the results for basic nursing education.

The purpose of this research was to use an expert and non-expert to focus on interface pressure in posture-changing techniques used in nursing and to explicit the tacit knowledge hidden in the skilled nurses. We estimated the amount of pressure dispersed during wheelchair transfers done by the expert and non-expert. The non-expert had his cervical spine in an anteflexion position during all the activities, and his ankle distance was not consistent when changing directions and sitting. Also, because his knee joint was in a flexion position when changing directions or seating, it became clear that the posture was not stable. Because of this, the non-expert had more aching parts and reported more fatigue than the expert after the activities. By analyzing the interface pressure, the transfer assistance done by the non-expert described above increased the contact pressure when seating the SP, and the area of contact was narrow and the seat was shallow, which suggests that the risk of tissue disorder and falling of the patient from a wheelchair were increased.

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