Ergonomics in Healthcare for Registered Nurses

References

This page is primarily a summary of the already succinct Self-Study Guide for Ergonomics in Healthcare for Registered Nurses by AnsellCARES, an educational institution. It has been further supplemented with the the following:

1. EDiS3: Ergonomic principles, Discomfort perception, and muscular Stretching interventions (2023)— an experimentally tested method for mitigating musculoskeletal discomfort.
2. Ergonomic Risk-prone Activities in the Intensive Care and Emergency Room: a paper on the development of a risk-assessment method and its implementation within the intensive care and emergency department.
3. Ergonomics in Nursing: primarily for their discussion on the alternative systems in place for safe patient handling in terms of lifting and moving patients.
4. No-Lift System at the Royal Melbourne Hospital: the policy used within RMH for their implementation of the No-Lift policy sometimes legally required in some states.
5. Occupational Safety and Health Administration (OSHA) on their publication on safe patient handling for preventing musculoskeletal disorders in nursing homes, discussion on ergonomics, and discussion on weight-lifting limitations by healthcare workers

Ergonomic risks present significant occupational hazards and are a source of injury, especially in the operating room practice setting. This discussion covers the causes and incidence of ergonomic injuries, characteristics of the operating room, roles of ergonomically designed gloves, and best practice techniques to reduce ergonomic-related injuries.

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Causes

The two leading causes of work-related ergonomic injuries among hospital workers are overexertion and bodily reactions (48%) such as lifting, bending, or reaching during patient handling, and slips, trips, and falls (STFs) (25%).

Fatigue is another cause of ergonomic-related injuries and staff accidents in the operating room. In particular, this refers to hand fatigue from tedious, repetitive tasks involved in surgical procedures. This is further exacerbated with the use of thick, rigid, slippery, ill-fitting, or uncomfortable gloves. In surgery, this is primarily related to work schedule, sleep, and the incorporation of comfort into the design of the OR and equipment.

Incidence

In the United States, 253,700 work-related injuries and illnesses were reported for 2011. Among these, nursing personnel were among the highest risk for musculoskeletal disorders (MSDs).

According to the United States Bureau of Labor Statistics list of occupations at-risk for sprains, strains, nursing personnel, nurse aides, orderlies, and attendants are listed as first and registered nurses (RNs) are sixth.

In the United States, 25% of nurses and nursing assistants change their shifts or took sick days to recover from an unreported injury, 80% report they frequently work with musculoskeletal pain. Work-related injuries were associated with lifting, pushing, and pulling; fatigue; slips, trips, and falls; and work design and repetitive actions.

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Ergonomic Considerations in the Operating Room

The surgical practice setting presents additional, unique challenges in regards to ergonomic-related injuries; the occupational hazards inherent to the perioperative practice setting include, but are not limited to transferring, positioning, and repositioning patients; reaching, lifting, and moving equipment; lifting and holding patient extremities for prepping; standing for long periods of time; and holding retractors for extended periods. This, in conjunction with hazards such as instrument placement and design, forward leaning awkward posture, neck posture, screen positioning, OR bed height, and foot pedal placement contribute to discomfort.

1. Standing For Long Periods of Time and Fatigue: discomfort in the legs, knees, feet, and lower back; joint locking, as well as varicose vein development. Maintaining static postures can result in surgical fatigue syndrome, which weakens coordination and also decreases reaction times.
2. Instrument Design and Placement: awkwardly-sized surgical instruments and other tools force upper arm movement away from the midline and flexion/ulnar wrist deviation, which can lead to upper body discomfort. Increased instrument weight and distance from hand to tool tip can result in neck and shoulder strain.
3. Forward-Leaning Positions: lower back muscular activity is used for positions that lean forward. Prolonged static flexion of the neck and lower back leads to pain in those areas.
4. Neck Posture and Screen Positioning: looking down requires neck flexion and also increases cervical spine pressure. In minimally invasive procedures (e.g. laparoscopy), neck posture becomes highly dependent on screen positioning— if the screen is above the line of vision, repeated extension to view the screen is done, causing strain.
5. OR Bed Height: beds are often set too high; if adjustable, these are typically fitted to the primary surgeon, despite surgical team members being various heights.
6. Foot Pedal Placement: pedals with small surface areas limit the range of motion and also require the use of static posture. If tension is high or the positioning is held for an extended period of time, discomfort may occur.

Hand Fatigue

As previously discussed, hand fatigue is common in the OR practice environment. Muscles, nerves, and tendons in the hands, wrists, and arms strain to meet the demanding, tedious, and/or repetitive actions required during surgical procedures, which can be aggravated by gloves that are thick, rigid, slippery, ill-fitting or uncomfortable. (AnsellCARES sells gloves, this might be a conflict of interest but eh).

Review of Anatomy

Carpal Tunnel Syndrome

Gloves that restrict hand movement will require the healthcare worker to exert more muscular effort in order to perform tasks, thereby increasing the risk of strain. Over time, strain caused by repetitive motion or prolonged exertion can lead to muscle fatigue, pain and even injury. In the case of carpal tunnel syndrome, the repetitive stress leads to the swelling and inflammation of tendons, which then creates pressure on the nerves. The affected person becomes symptomatic, with symptoms including burning, tingling, or numbness in the palms and fingers that generally start out gradually. This eventually results in a loss of grip strength, making basic manual tasks difficult. Without treatment, this can cause significant, permanent muscle loss at the base of the thumb. Similar symptoms may also appear in other overuse injuries.

Key Considerations in Glove Use for Hand Fatigue

1. The types of gloves worn will affect the amount of hand and finger force associated with a specific task.
2. Improperly-sized gloves can either slip too easily, or compress the sensitive muscles with the palm and thumb region, eventually leading to chronic discomfort as well as impairment in mobility.
3. As glove thickness increases, tactile sensitivity decreases, which affects instrument/device manipulation.

Ergonomic glove design primarily takes into consideration exertion measurements and comparisons, fit, comfort, performance, tactile sensitivity, donning, and grip. Secondarily, electromyographic measurements were used to quantify muscle effort exerted by individual muscles in the hand during the assigned tasks. These are contrasted with bare-handed use and during the use of comparable products.

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Best Preventive Practices

There are many established regulations and best practices outlined by professional nursing associations to prevent ergonomic-related injuries in the O.R.

State No-Lift Laws

In the United States, safe patient handling laws have been published that prohibit the lifting of any patient except in cases of emergency. This is primarily set in place to improve patient safety, but also to reduce carer/healthcare worker injury. In assistance to move is required, staff may use devices to ensure comfortable and safe movement. This may include slide sheets, stand-up lifting machine, lifting machine, turning frames, lateral transfer aids, transfer chairs, gait belts, bedding modifications, geriatric chairs, etc.

Occupational Safety and Health Administration (OSHA) on Safe Patient Handling

Consultation via letter with OSHA (Thomas Galassi) last 2014 yielded a response that, while OSHA does not enforce a minimum amount of lifting required for employees, The American Journal of Nursing (2007, 107(8), 53-58) states that “In general, the revised [NIOSH] equation yields a recommended 35-lb. maximum weight limit for use in patient-handling tasks.”

In the United States, OSHA is a body that enacts laws for employers to ensure workplace safety. They present many salient points in their publication for safe patient handling in nursing homes:

1. Patients must realize the ease and comfort of modern mechanical lifts to accept them. The use of mechanical lifts makes care safer for both patients and healthcare workers. It is a misconception to think manual lifting is safer or more comfortable than mechanical lifting.
2. There is no such thing as safe manual lifting of a patient. Proper body mechanics, while helpful, is not by itself an effective way reduce the incidence of injuries.
3. Patient-handling Injuries are necessary even for healthy workers. Manual lifting can cause micro-injuries to the spine that cumulatively results in debilitating injury. Experts recommend that lifts be limited to 35 pounds or less. Contrarily, good health and strength may put workers at increased risk as they are assigned to manual work such as lifting patients.
4. It is faster to use mechanical lifting equipment than manually moving patients (except in some emergent cases). Convenient placement of the equipment is important, and rounding up a team of workers to lift patients is often more time-consuming than to get safe patient handling equipment.
5. The use of mechanical lifting is, in fact, cheaper than manual lifting. Injuries will result in the loss of work days. Annually, the healthcare industry loses an estimated $20B from worker compensation, lost productivity, and turnover.

For a successful safe patient handling program, (a) all levels of management must be committed, (b) a safe patient handling committee involving frontline workers must be formed, (c) hazard assessment must be performed, (d) technology and prevention through design is utilized to its best degree, and (e) education and training is provided to each worker, including the use of appropriate patient lifting equipment, review of evidence-based practices, and training for when and how to report injuries.