Ergonomics is the practice of designing equipment and work tasks to conform to the capability of the worker, and it provides a means for adapting the work environment and work practices to prevent injuries.1 Perioperative nurses and other surgical personnel are continually at risk for work-related musculoskeletal injuries. Patient handling, equipment and instrument carrying, and static motion are some of the examples that contribute to this injury risk. To reduce this risk, nurses must work together to develop a plan for an ergonomically healthy workplace.2
The Association of periOperative Registered Nurses (AORN) published a position statement outlining ergonomically healthy workplace practices. This document outlines strategies to reduce the risk of injury and provides guidelines for developing a plan for an ergonomically healthy perioperative environment.1 During the time it takes to organize the team, assess the workplace, and develop a plan, perioperative staff can focus on individual, physical work behaviors each day to reduce the risk of back and other musculoskeletal injuries.
Using a table format, this article is intended to explore risk factors for musculoskeletal injury and to provide practical evidence-based techniques and behaviors to lessen musculoskeletal injury risk for perioperative nurses and staff.
A common problem
Imagine walking through the physical therapy (PT) department and seeing your coworker, a perioperative nurse of 26 years, as the patient. Now picture that same nurse as she begins a rehabilitation regimen after a work-related injury. Hard to imagine? This scenario isn't all that far-fetched; 38% of nurses suffer from back pain so severe they must take time off from work. In addition, up to 12% of nurses have such severe back pain that they must leave nursing altogether.3
In 2004, 54% of workplace injuries among nursing, psychiatric, and home health aides were musculoskeletal disorders (MSDs). The U.S. Department of Labor defines MSDs as injuries or disorders of the muscles, nerves, tendons, joints, cartilage, or spinal discs.4
Research
The nursing profession continually seeks to validate practice with research evidence and this evidence enables nurses to use scientific data to provide a basis for their actions. So, in order to find a scientific resolution to workplace injury and apply ergonomics, research will be the key.
One research study5 noted that although nurses have one of the highest rates of work-related musculoskeletal injury when compared with other professions, efforts to reduce work-related musculoskeletal disorders in nurses have mostly been unsuccessful over the past 30 years. This same study found that when deciding how to reduce risk of injury, solutions (interventions) that include multiple factors are more successful than an individual intervention.5
Findings from peer-reviewed research show that ergonomic interventions are effective in significantly reducing the risk of musculoskeletal disorders.6
Applying the research
The AORN position statement, "Ergonomically healthy workplace practices," proposes a three-fold approach to promoting ergonomic safety in the perioperative setting. These include administrative, engineering, and behavioral controls. Administrative controls include development of an ergonomic safety culture, development and implementation of policies, ergonomic assessment protocols, staff education, and work design. Engineering controls include adaptation of tools, workstations, and equipment, maintaining adequate room lighting, and availability of appropriate patient handling equipment. The third of these three approaches is the behavioral control group. These behavioral interventions can and should be practiced by all perioperative team members all the time to reduce the risk of injury in the perioperative environment.1 The charts in this article outline behavioral controls. Information on the administrative and engineering controls is available in the AORN position statement.
Safety is our responsibility
Ergonomics research provides safe interventions to avoid musculoskeletal injury within the perioperative setting. Perioperative leaders and other team members must use these available resources in order to help make the workplace an ergonomically safer place for all.
Perioperative nurse behaviors1,5
Risk factors for musculoskeletal injury
* Manual lifting or moving patients that are fully dependent/anesthetized without enoughassistance
* Lateral transfers of patients from stretcher to OR bed
* Vertical positioning of patients on a stretcher or OR bed
* Moving patient care equipment
* Positioning patient extremities
* Holding patient extremities during skin preps
* One person prepping and holding patient extremities
* Static posture-continually standing in one position during lengthy surgical procedures
* Awkward postures from tilting head downwards for long periods of time
* Prolonged use of upper body while retracting patient anatomy during surgery
* Transporting patient on OR stretcher from one environment to another
* Reaching for supplies on shelves above the head
* Carrying heavy instrument trays
* Bending down to reach sterile field while scrubbed or assisting surgeon
* Bending down to pick up items on the floor or on low shelves
* Falling over portable equipment, electrical cords, debris or liquids on the floor
* Standing on hard work surfaces such as concrete, creating trauma and pain in the feet
* Forceful tasks such as pushing a patient on a stretcher up a ramp
* Repetitive motion such as passing instruments, opening suture packages, and typing
* Overexertion while protecting a combative patient emerging from anesthesia
Behavioral controls to reduce risk of musculoskeletal injuries in perioperative settings1,2,7
Lifting, patient handling, transferring, and repositioning guidelines
* Don't transfer patients when off balance.
* Lift loads close to the body.
* Never lift alone, particularly fallen patients. Use team lifts or mechanical lifting devices (if trained properly in their use).
* Avoid heavy lifting, especially with spine rotated.
* Avoid repetitive motions as much as possible (such as manual crank adjustments on beds).
* Don't reach across beds to lift patients.
* Avoid pushing stretchers up ramps with a great deal of force.
* Don't lift heavy objects or patients alone.
* Avoid overexertion, such as trying to stop a patient from falling or picking up a patient after a fall without assistance.
* Avoid moving or lifting totally dependent patients alone, including anesthetized patients.
* Use lateral transfer devices and at least four team members to move patients from bed to stretcher or vice versa.
Preventing slips and falls
* Eliminate uneven floor surfaces.
* Clean up spills on the floor immediately.
* Eliminate cluttered or obstructed work areas.
* Cover equipment cables across the floor with wide tape or cable covers affixed to the floor.
* Keep aisles and passageways clear of obstruction and in good repair.
* Use ceiling or floor outlets in a manner that reduces cords or cables crossing over floors.
* Mark mobile equipment with a bright color, or a tape "X", to help distinguish it from the floor and make it more visible to employees.
* Turn on lights when entering a room to provide adequate lighting.
Avoiding static or awkward postures
* Use footstools when possible.
* Wear shoes with well-cushioned insteps and soles.
* Use a footrest bar or a low stool to alter posture by raising one foot.
* Use height adjustable work surfaces.
* Avoid twisting your spine and body, bending laterally or to the side while lifting.
* Don't hyperextend or flex your back.
* Learn proper lifting techniques from an ergonomic resource person (such as the PT department or ergonomics staff).
* Match team lifting to assessment of load to be lifted.
Transferring or transporting equipment
* Place equipment or instrument trays on a rolling device if possible for easier transport.
* Push rather than pull equipment when possible. Keep arms close to your body and push with your whole body, not just your arms.
* Assure that passageways are unobstructed.
* Get help moving heavy or bulky equipment or equipment that obstructs vision.
* Don't transport a patient with multiple equipment or multiple items by yourself (such as a patient in a wheelchair with an I.V. pole).
Reaching or lifting when moving trash or laundry bags
* Limit the size and weight of these bags and transport in containers with handles.
* Place receptacles in unobstructed and easy-to-reach places.
* Keep carts, hampers, and stretchers well maintained to minimize force exerted when using these items.
* Keep handles of devices to be pushed at waist-to- chest level.
* Use handles to move carts rather than the side of the cart to prevent hand and finger injury.
* Keep floors clean and well-maintained.
* Push rather than pull whenever possible.
* Remove all malfunctioning carts from use.
* Get help with heavy or bulky loads.
Reducing wrist, arm, and shoulder strains or sprains
* Use properly designed instruments and only use for the designated task.
* Use padding (such as lap sponges) around hand- held retractors when using for prolonged periods.
* Keep the wrist straight while doing finger-intensive tasks. Select ergonomic tools and instruments.
* Use the lightest instrument available.
Housekeeping tasks
* Alternate leading hand when cleaning.
* Avoid tight and static grip and use padded and nonslip handles.
* Clean objects at waist level, if possible, and avoid bending over the object.
* Use tools with extended handles or step stools and ladders to avoid or limit overhead reaching.
* Avoid awkward postures (such as twisting or bending) while cleaning.
* Use spray bottles and equipment that have trigger bars rather than single-finger triggers.
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