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Background: Work-related physical discomfort exists within the optometric profession. It is not well understood how optometrists manage this issue in their workplaces.
Method: An online questionnaire was sent by e-mail to approximately 1,700 Australian optometrists. Participants were asked if they experienced work-related discomfort in any of eight nominated body regions. If so, they were asked to describe specific work tasks, which contribute to their work-related discomfort, and strategies they have adopted to minimise their discomfort. These data were subject to qualitative and quantitative analyses.
Results: There was a 25 per cent response rate and 416 optometrists participated in the questionnaire. Work-related physical discomfort was reported by 339 respondents (81 per cent), most commonly with the use of the phoropter (n = 144, 35 per cent) and slitlamp (n = 94, 23 per cent). Males were more likely to report lower back discomfort with phoropter use (Chi-squared, p < 0.01) and ophthalmoscopy (Chi-squared, p < 0.01). To minimise discomfort, optometrists 41 years and older were more likely to report that they adjust their posture (Chi-squared, p < 0.03) and females were more likely to report that they alter their work schedule (Chi-squared, p < 0.05). A recurrent theme expressed by participants was an inability to make changes to improve their comfort due to room and equipment design, poorly maintained equipment, non-supply of suitable equipment or furniture and inherent difficulties within optometric tasks.
Conclusion: There is a need for all optometrists to have skills to evaluate their own personal risk of discomfort in the consultation room. Owners and managers of optometric practices also need greater awareness of the importance of room and equipment design and maintenance on work-related discomfort. This has implications for the well-being of optometrists, for their productivity and for compliance with health and safety legislation.
Optometrists strive to provide optimal vision care for patients and promote optimal visual conditions in workplaces. In short, optometrists care about the visual welfare of others but do we also look after our own health and well-being while at work?
Australian optometrists may examine up to 20 patients per day and during each eye examination perform clinical procedures, which require them to bend and twist their bodies, stand and sit in awkward postures or hold their arms outstretched while making fine movements with their hands and fingers. In an earlier paper, we reported a survey, which showed that Australian optometrists report physical discomfort at work (82 per cent of survey respondents and at least 20 per cent of all optometrists in Australia)1 and established that work-related physical discomfort is more likely for females and for young optometrists.
Independent risk factors for severe discomfort (discomfort present for more than 30 days) include performing repetitive tasks and continuing to work while injured.1 Other reasons postulated for ophthalmic work-related discomfort include static postures while working with patients,2,3 awkward postures,3 high patient loads1,4 and high stress levels.4 The consequences of work-related discomfort in ophthalmic practitioners includes hospitalisation,1,2 reduced ability to perform tasks4 and reduced work hours.5,6
Work-related discomfort among optometrists may be perceived as common and unavoidable,7 but this does not diminish the legal obligations of employers to ensure the health and welfare of their employees8,9 and indeed themselves, particularly when a risk has been identified. Understanding the reasons for work-related discomfort and potential strategies for effectively reducing discomfort is imperative to meeting these legal obligations and for compliance with the internationally accepted risk management approach10 to identify, treat and manage risks.
Maintaining comfort in the consultation room is also important for the longevity of the optometric workforce. Australians born after 1 July 1964 must be 60 years-of-age before they can access superannuation savings11 and eligibility for the Australian Government Age Pension has recently been increased to 67 years for men and women born after 1957.12 This means that an Australian optometric student, who completes five years of tertiary study directly after leaving high school will be aged approximately 23 years upon graduation and therefore could expect to be working in the profession for more than 40 years. Subsequently, there are significant direct and indirect costs to individuals and to the community if practitioners are lost to the profession due to work-related injury.
There are publications that offer practical advice for reducing the risk of work-related discomfort in ophthalmic practitioners. These appear to be largely based on the respective authors' observations of practitioners and their own experiences in the consultation room3,6,13–18 or predictions of possible causes of work-related discomfort by analysis of underlying injury mechanisms.3
This paper differs from these other publications in that it measures optometrists' experience of work-related discomfort by surveying the Australian optometric population and investigates discomfort associated with all work tasks, not just ophthalmic procedures. The purpose of this paper is to identify tasks associated with work-related physical discomfort in Australian optometrists and describe how Australian optometrists modify their workspace to decrease the impact of discomfort. This knowledge is important for implementing risk management processes in optometric practices and for providing direction for future investigations into this issue.
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An online questionnaire was constructed with questions about work-related discomfort in eight different body regions. A link to this questionnaire was sent by e-mail to members of Optometrists Association Australia (OAA) Australia-wide in August 2008. The study was approved by the Human Research Ethics Advisory Panel of the University of New South Wales. There was implied consent if optometrists chose to complete and submit the questionnaire.
The questionnaire consisted of three parts: Part 1 asked if the optometrist had experienced discomfort in any of eight body regions during the previous 12 months. The term ‘discomfort’ was defined in this study as pain, ache, difficulty with movement and numbness. Part 2 contained questions specifically related to the body parts: neck, shoulder, upper back, lower back, elbow/arm, wrist/hand, knee/leg and ankle/foot and was partially based on the standardised Nordic questionnaires for the analysis of musculo-skeletal symptoms in an occupational setting19 and job factors, which contribute to discomfort listed by Bork and colleagues.20 A separate page for each body region was constructed with identical questions on each page and labelled Sections A to H. Part 3 included demographic questions. Table 1 gives a summary of the questions used in the questionnaire. A more detailed description of the construction of the questionnaire and its distribution are given elsewhere, together with the independent risk factors for any discomfort and for severe discomfort.1
Table 1. Summary of content of the questionnaire
| || Questions subject to quantitative analysis || Questions subject to qualitative analysis |
|Part 1||Have you experienced discomfort in any of eight body regions (neck, shoulder, upper back, lower back, arm/elbow, wrist/hand, knee/leg and ankle/foot) during the previous 12 months?|| |
|Part 2||Questions based on the Nordic Musculoskeletal questionnaires19 including:||Do any specific work tasks or ophthalmic techniques increase your discomfort?|
| Need for consulting another healthcare practitioner or requiring hospitalisation for discomfort||Have you been able to modify your work or your work space to decrease your discomfort?|
| Length of time experiencing discomfort in previous 12 months|
| Whether discomfort has resulted in an inability to perform work-related or leisure-related activities|
|A question asking participants to nominate factors that contribute to personal discomfort, based on Bork and colleagues20 (e.g. performing repetitive tasks, examining a large number of patients per day)|
|Part 3||Demographic questions including:|| |
| Years working as an optometrist|
| Employment status|
| Hours working per week as an optometrist|
| Number of eye examinations conducted per day|
The qualitative data collected from Part 2 of the questionnaire are presented in this current paper. These data were transferred to a Microsoft Excel file (Microsoft Corporation, Richmond, WA, USA) and manually coded into themes and sub-categories for each body region. Tasks contributing to discomfort were coded into the categories: ocular health examination, refraction and recording information. Strategies for reducing discomfort were coded into the categories: adjust equipment, adjust posture, perform alternative clinical procedures, alter the work schedule and stretching and relaxation exercises. Some participants reported multiple tasks contributing to discomfort in one body region or multiple strategies for reducing discomfort. Therefore, the total number of reports may exceed the number of respondents.
Chi-squared analysis was conducted to establish whether there were any associations between demographic factors or reports of severe discomfort and the number of participants who reported specific tasks contributing to discomfort and strategies for reducing discomfort. Statistical significance was set at p = 0.05. To ensure sufficient numbers within categories, the demographic factors were divided into the categories: male and female, aged 21 to 40 years and age 41 years and over and self-employed/employee and locum. ‘Severe discomfort’ was defined as discomfort present for more than 30 days.
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There were approximately 1,700 optometrists with active e-mail addresses on the OAA e-mail database at the time the questionnaire was issued. The response rate to this questionnaire was 25 per cent (416 competed questionnaires) with 339 respondents reporting work-related discomfort. The results presented in this paper are gathered from these 339 respondents. There were 183 males (44 per cent) and 165 optometrists aged 41 years or older (40 per cent), who participated in this questionnaire. This is slightly less than the number of males (55 per cent) and optometrists aged 40 years or more (50 per cent) reported in the Australian optometric population in July 2009.21
Tasks associated with ocular health examination (slitlamp examination and ophthalmoscopy) and refraction (phoropter and use of hand-held equipment) were the most frequently reported tasks associated with discomfort (Table 2) and with severe discomfort (Table 3). There were eighteen participants who reported severe discomfort associated with three or more clinical tasks (Table 3). Males were more likely to report lower back discomfort associated with the use of the phoropter (p < 0.01) and ophthalmoscopy (p < 0.01). Computer-related discomfort was cited by 60 participants. Explanations for this include ‘twisting neck to see computer and then speak to the patient’, ‘working at the computer for long periods’ and ‘(using the) computer at awkward angles’.
Table 2. Body regions affected for the five most commonly reported tasks contributing to discomfort
| || Participants reporting discomfort† || Neck discomfort || Shoulder discomfort || Upper back discomfort || Lower back discomfort || Elbow/arm discomfort || Wrist/hand discomfort || Knee/leg discomfort || Ankle/foot discomfort |
| N || N || % || N || % || N || % || N || % || N || % || N || % || N || % || N || % |
|Computer and writing tasks||Total|| ||60||19||32||14||23||8||13||5||8||8||13||23||38||0‡||0||0‡||0|
|Trial frame / trial lenses / hand held equipment, for example, occluder, prism bars||Total|| ||34||9||26||15||44||1‡||3||3‡||9||2‡||6||4‡||12||0‡||0||0‡||0|
Table 3. Severe discomfort (discomfort present for more than 30 days) reported by participants
| || Any severe discomfort† || Neck discomfort || Shoulder discomfort || Upper back discomfort || Lower back discomfort || Arm/elbow discomfort || Wrist/hand discomfort || Leg/knee discomfort || Ankle/foot discomfort |
| N || %‡ || N || %‡ || N || %‡ || N || %‡ || N || %‡ || N || %‡ || N || %‡ || N || %‡ || N || %‡ |
|Computer and writing tasks||19||32||8||42||4||29||3||38||1||20||1||13||9||39||0||0||0||0|
|Trial frame / trial lenses / hand held equipment, for example, occluder, prism bars||13||38||4||44||6||40||0||0||2||60||2||100||1||25||0||0||0||0|
|Severe discomfort reported (with or without nominating specific work tasks that contribute to discomfort)||169||—||89||—||72||—||56||—||57||—||14||—||21||—||8||—||3||—|
|Severe discomfort described for 1 or 2 specific work tasks||115||—||68||—||29||—||29||—||29||—||4||—||16||—||1||—||2||—|
|Severe discomfort described for 3 or more specific work tasks||18||—||5||—||3||—||2||—||7||—||1||—||2||—||0||—||0||—|
There were 156 participants who described strategies for reducing discomfort (90 females; 89 aged younger than 41 years; 81 self-employed). Adjusting the equipment and adjusting posture were the most common strategies reported by participants to decrease their discomfort (Table 4). Optometrists 41 years and older were more likely to report that they adjust their posture (p < 0.03) and females were more likely to report that they alter their work schedule (p < 0.05), for example, stop full-time work, decrease the number of patients they see or cease performing some tasks. Engaging the assistance of others, for example, ‘get others to do frame adjustments’ or ‘I ask my kids and husband to lift equipment for me’ indicates that work-related discomfort may also have ramifications for optometrists' families and work colleagues.
Table 4. Strategies adopted to reduce discomfort
| Strategy || Demographics of participants who reported a strategy || Specific strategies‡ |
| || || N || % || || N || % |
|Adjust posture||TOTAL|| ||93|| ||Total citations for all body sites||134|| |
|Gender||Male||41||44||Adopt ‘better’ posture / change posture / adjust positions||59||44|
|Female||52||56||Stand for procedures||25||19|
|Employment||Self-employed||49||53||Work bilaterally / alternate sitting and standing / change hands||20||15|
|Employee/locum||44||47||Sit whenever possible for procedures||18||13|
|Age† (years)||21–40||46||49||Support hand/arm||12||9|
|41+||47||51|| || || |
|Adjust equipment||TOTAL|| ||74|| ||Total citations for all body sites||123|| |
|Gender||Male||29||39||Adjust height of patient chair / practitioner chair / equipment||65||53|
|Employment||Self-employed||37||50||Adjust computer arrangement on desk / rearrange consultation room / move to a larger office / alternate between consultation rooms||25||20|
|Employee/locum||37||50||Wear good shoes / wear trousers instead of skirt||5||4|
|Age (years)||21–40||45||61|| || || |
|41+||29||39|| || || |
|Perform alternative procedures||TOTAL|| ||26|| ||Total citations for all body sites||38|| |
|Gender||Male||11||42||Indirect ophthalmoscopy / slitlamp fundoscopy / digital imaging instead of direct ophthalmoscopy||19||50|
|Female||15||58||Computerised phoropter / automated equipment||7||19|
|Employment||Self-employed||15||58||Hand held tonometer / non-contact tonometer||6||16|
|Employee/locum||11||42||Stop using trial frame / use more retinoscopy||4||10|
|Age (years)||21–40||18||69||Less typing / alternative word processing program||2||5|
|41+||8||31|| || || |
|Alter work schedule||TOTAL|| ||13|| ||Total citations for all body sites||22|| |
|Gender†||Male||2||15||Stop full-time work / cease conducting home visits / change job tasks / decrease number of patients||10||45|
|Female||11||85||Take rest break / lunch break||6||27|
|Employment||Self-employed||5||38||Perform tasks faster||3||14|
|Employee/locum||8||62||Delegate tasks and procedures to other staff / family members||3||14|
|Age (years)||21–40||7||54|| || || |
|41+||6||46|| || || |
|Stretching and relaxation exercises||TOTAL|| ||16|| ||Total citations for all body sites||20|| |
|Gender||Male||4||25|| || || |
|Female||12||75|| || || |
|Employment||Self-employed||7||44|| || || |
|Employee/locum||9||56|| || || |
|Age (years)||21–40||7||44|| || || |
|41+||9||56|| || || |
Twenty participants reported that they have adopted the use of technology (for example, computerised phoropter, digital retinal imaging) or relocated their practice to facilitate extra space as a means of reducing discomfort; however, simply replacing one technique or piece of equipment for another does not necessarily ensure that discomfort will be totally eliminated. For example, one participant who installed a computerised refractor head to alleviate elbow and arm pain had ‘to sit, which aggravates back/neck problems’, while two participants reported that changing their posture has since resulted in discomfort in other body regions.
A recurrent theme expressed by participants was that although they could identify the cause of their discomfort, they were unable to make the necessary changes. There were 18 participants who reported that their discomfort was not totally alleviated even after implementing strategies (10 females, 14 optometrists aged less than 41, 12 employee/locum optometrists), five of whom reported severe discomfort with three or more clinical tasks, for example, ‘I now do refractions standing so that my arm is lower. This helps but it still hurts’. Other barriers to improving comfort included:
room and equipment design, for example, ‘(I) ensure (the) slitlamp and seat are the correct height but (this) does not prevent problem’
poorly maintained equipment, for example, ‘the phoropter movement (is) not well maintained’
non-supply of suitable equipment or furniture, for example, ‘practice refused to upgrade (the) slitlamp or chair’
inherent difficulties within optometric tasks themselves, for example, ‘(I) have tried (different strategies to reduce discomfort) but the task needs to be done’.
This suggests that more holistic and strategic solutions might be required for managing work-related discomfort, rather than simply relying on a prescriptive approach, for example, recommending a specific item of equipment or advocating a particular posture for performing a clinical task.
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This paper supports anecdotal reports within ophthalmic literature that work-related physical discomfort is related to specific ophthalmic tasks and techniques. The two most commonly cited ophthalmic tasks involved the phoropter and the slitlamp and were associated with neck, shoulder and back discomfort. Some of the contributing factors to discomfort (for example, inability to adjust equipment) and strategies to reduce discomfort (for example, adjust posture or equipment, reduce patient contact hours) reported in this questionnaire have also been reported in other professions, for example, veterinary science,22,23 physical therapy,24,25 nursing26 and dentistry.27,28 The results also identify non-ophthalmic factors contributing to discomfort that have not been described previously, for example, room and equipment design and equipment supply and maintenance.
Why do individuals continue to work in conditions that contribute to personal discomfort? Although the answer to this specific question requires further investigation, it is clear from the results that discomfort is not experienced by an isolated few. There may be response bias associated with the survey in that optometrists who experience work-related discomfort might have been more motivated to participate in this anonymous questionnaire. Nevertheless, the total number of participants who reported work-related discomfort (n = 339) is likely to be a lower estimate of the total number of Australian optometrists who actually experience discomfort.
It is possible that some optometrists experience discomfort because they have not recognised a link between their discomfort and specific work tasks or because they have been unable to determine a practical solution for their problem. This is not necessarily a poor reflection on the individual but might reflect the fact that solutions to problems are not always self-evident and might require a more strategic approach than trial and error or ‘common sense’.29,30
Identifying the best solution for discomfort might also be complicated by variations in personal physical stature, design of equipment and room arrangement. This might explain apparent contradictions in the reported strategies (for example, some practitioners advocate sitting during an eye examination while others prefer standing) and the debate within the ophthalmic literature as to whether it is better to sit or to stand for refraction18 or to alternate sitting and standing.14
Investigations within other healthcare professions31–35 suggest that work-related discomfort is best addressed using a multifactorial approach and that there is unlikely to be a single solution that is suitable for all practitioners. This is consistent with previous findings1 that removing the two independent risk factors for severe discomfort in optometrists (that is, performing repetitive tasks and continuing to work while injured) will not totally eliminate the risk of discomfort but only reduce the disease load in optometrists by 28 per cent. The variety of strategies described by participants in the present study supports the idea that work-related discomfort is multifactorial, while the barriers to improving comfort described by participants indicate that work-related discomfort might need to be addressed at different levels within the profession, for example, equipment design, consultation room design, practice management, as well as by individuals. The results presented in the present paper provide a useful starting point for implementing remedial action at these various levels.
It is alarming to discover that equipment supply and maintenance, and equipment and room design were reported as issues in some workplaces and that some participants were unable to make basic changes to improve their own comfort. Some participants reported that they manage their own discomfort by delegating tasks to staff or other family members. This raises the question whether there are inherent dangers performing some tasks and whether staff or family members are also at risk of sustaining a similar injury. In Australia, employers have an obligation to ensure the health and welfare of all people within the workplace. The risk management process10 recommends effective communication and consultation with stakeholders (for example, the workers) and that any interventions to control risk should be monitored and reviewed to ensure that subsequent risks do not arise (including risks to other people). Further evaluation on a case-by-case basis (for example, interviews and observations) would be necessary to determine if individual practices comply with occupational health and safety legislation and to develop strategies to encourage compliance within these workplaces.36
The results also highlight the fact that new technology is not necessarily a panacea for work-related discomfort but needs to be monitored and reviewed on an ongoing basis, just as for any other intervention. For example, several participants report that since introducing alternative technology to reduce work-related discomfort, they now experience discomfort in other body regions. Desktop computers in the consultation room were reported as contributing factors to discomfort, indicating that some optometrists might not have set up their own computer workstations correctly for physical and visual comfort. Attending to this issue provides two opportunities for optometrists. First, workstation arrangements that allow neutral postures can reduce personal risk of work-related discomfort;37 it also allows practitioners to demonstrate that they are able to apply basic ergonomic principles (which is a core competency for optometric practice in Australia38), particularly if these practitioners give advice to their patients on vision and visual ergonomics for computer use.
This questionnaire used an exploratory approach (open-ended questions) to identify factors contributing to discomfort and strategies adopted for managing discomfort. Subsequently, non-ophthalmic factors (for example, equipment maintenance issues) were described and these issues have not been reported previously in ophthalmic literature. The use of open-ended questions meant that some participants did not always provide comprehensive explanations, which hampered categorisation of the data. For example, it is unclear from the responses whether the response ‘slitlamp’ includes fundoscopy and gonioscopy or refers only to examination of the anterior eye. Despite this, the qualitative results indicate that use of the slitlamp, whether this includes fundoscopy and gonioscopy, is a contributing factor to neck, back and upper limb discomfort. This is consistent with predictions reported by Marx, Wertz and Dhimitri.3
It is possible that slitlamp examination and refraction were reported most frequently because they are the primary tasks performed by optometrists during a routine eye examination. Unlike other studies,20 this questionnaire did not include quantitative measures to assess the relative contribution of factors to work-related discomfort (for example, asking participants to rate the contribution of individual tasks and procedures on a Likert scale), since including such questions would have increased the length of the questionnaire and might have discouraged participation.39,40 Although quantitative information is useful for risk management (consequence-likelihood) matrices, these analyses are subjective and it has been argued that it might be a better use of resources to identify and control hazards rather than attempting to quantify and assess risks.41
Psychosocial factors (for example, workload, work satisfaction, job design) can contribute to work-related discomfort.42 Some participants alluded to these issues, which have been identified previously as risk factors for discomfort (for example, performing more than 11 consultations per day, not being self-employed).1 It is also possible that non-work-related injuries could be contributing to discomfort in some individuals. Other research methods, such as interviews with optometrists, are likely to be a better research method for exploring these issues43 and therefore these topics will be the subject of further investigation.