AORN Position Statement on

Ergonomically Healthy Workplace Practices

PREAMBLE
Perioperative registered nurses, along with other health care professionals, are routinely faced with a wide array of occupational hazards that place them at risk for work-related musculoskeletal injuries. "Musculoskeletal disorders represent one of the most frequently occurring and costly occupational issues in nursing."¹ Multiple occupational hazards create a risk of musculoskeletal injuries that include, but are not limited to, muscles, nerves, tendons, ligaments, joints, cartilage, and spinal discs.²

Contributing factors that can bring about injury include duration, frequency, and magnitude of ergonomic stressors. Examples of ergonomic stressors encountered during patient handling tasks include

forceful tasks (eg, pushing a stretcher and patient up a ramp);
repetitive motion (eg, passing instruments, opening suture packets, typing);
awkward posture (eg, holding retractors during a surgical procedure, lifting or holding patient extremities);
static posture (eg, standing for long periods of time in one position);
moving or lifting patients and equipment (eg, lifting without assistance);
carrying heavy instruments and equipment (eg, removing a sterilized tray of instruments from the autoclave); and
overexertion (eg, protecting a combative patient emerging from anesthesia).

Among occupations at risk for strains and sprains, in April 2002 the Bureau of Labor Statistics ranked nursing aides, orderlies, and attendants as number two and registered nurses as number six. "The rate of overexertion injuries among hospital nurses almost doubles that of workers in private industry. In 1990, the national goal was to decrease these injuries in nursing personnel from 12.7 injuries per 100 full-time nurses annually to nine. According to one source, however, the rate actually had increased to 17.8 injuries per 100 nurses by 1995."³

"Among nurses, back, shoulder, and neck injuries are the most prevalent musculoskeletal disorders (MSDs). In 2001, nurses in the private sector had 11,800 MSDs, most of which (almost 9,000) were back injuries. Likewise, more than a third (36%) of the injuries requiring time away from work were back injuries. Studies of back-related workers' compensation claims show that nursing personnel have the highest claim rates of any occupation or industry. A recent study found that slightly more than half of all nurses (52%) complain of chronic back pain. According to an older study, 12% of nurses who intended to leave the profession cited back injuries as either a main or contributing factor."⁴

Cumulative trauma disorders (CTDs) most often affect upper extremities (eg, wrists, fingers, shoulders, elbows). Cumulative trauma disorders, also known as repetitive strain injuries, are physical problems affecting joints and soft tissues (eg, muscles, tendons nerves). Limited range of motion or a reduction in the ability to grip objects can occur if a CTD is left untreated. Discomfort, swelling, or muscle fatigue that does not disappear with rest are the beginning signs of a CTD. The aching muscle may feel as if it has been strained or overused. Another sign is tingling or numbness. All these symptoms may become chronic for perioperative registered nurses and can result in muscle weakness and nerve problems.⁵ Perioperative registered nurses with these symptoms may have difficulty providing patient care and performing specific activities (eg, opening supplies, passing instruments, computer documentation, lifting instrument pans).

Perioperative registered nurses also are prone to pain and fatigue from static posture during surgical procedures. Static posture puts an increased load or force on muscles and tendons that impedes the flow of blood needed to bring nutrients and carry away waste products of metabolism. The longer the posture must be maintained, the more the potential for fatigue and muscle-tendon strain.⁶

Pain and fatigue can be the result of standing in one place for long periods of time. Employees that experience pain and fatigue are

less productive,
less attentive,
more prone to make consistent mistakes,
more susceptible to injury, and
more likely to affect the health and safety of others.

Research from the University of Pittsburgh has shown that there is a direct relationship between safety and productivity in the workplace.⁶

POSITION STATEMENT
AORN is committed to the attainment and maintenance of an ergonomically healthy workplace to protect all employees in the perioperative setting. Therefore, AORN believes that every organizational perioperative setting should be ergonomically safe to decrease or prevent injury to the health care worker. Safe working conditions must be a top priority for all health care organizations. Each organization's leadership team should assess, identify, develop, and implement risk reduction strategies for injury prevention using an ergonomic approach. AORN supports research that is directed toward creating and maintaining equipment and work tasks to conform to the capability of the perioperative health care worker. AORN further supports collaboration with the National Institute for Occupational Safety and Health, Occupational Safety and Health Association, and state and local regulation to promote ergonomic safety in the perioperative environment.

AORN believes that risk-reduction strategies in the following areas should be considered when developing a plan for an ergonomically healthy perioperative environment.

Administrative Controls

Develop a culture of ergonomic safety.
Develop and implement a policy for manual patient handling.
Develop and implement patient care ergonomic assessment protocols.
Limit the weight of instrument trays.
Educate and train staff in the use of patient handling devices and strategies to prevent musculoskeletal injury.
Design and implement ergonomic work stations.

Engineering Controls

Maintain adequate room lighting.
Have available appropriate assistive patient handling equipment.
Adapt workstations, tools, and equipment for ergonomic safety.

Behavioral Controls

Have available ergonomic clinical advisors and/or resources.
Wear nonskid footwear.
Remove or eliminate clutter.
Keep cabinet doors and room doors closed.
Clean up spills or debris immediately.
Cover equipment cables across the floor.
Use lift teams to handle patients.
Inspect furniture wheels frequently for buildup of debris.

This position statement articulates AORN's position regarding ergonomic safety in the perioperative environment based on available research at this time.

GLOSSARY
Administrative controls: Administrative or management control of workplace practices (eg, providing adequate staffing levels).⁷

Awkward posture: Tilting the head downwards for long periods of time; twisted, hyperextended, or flexed back and neck positions.⁸

Cumulative trauma disorder (CTD): Cumulative trauma disorders are physical problems affecting joints and soft tissues such as muscles, tendons, and nerves. Cumulative trauma disorders most often affect the wrists and can damage fingers and elbows.⁵

Engineering controls: Designing equipment and workplaces to prevent or reduce the incidence of injury to the worker.⁷

Ergonomics: "The science of fitting the job to the worker. When there is a mismatch between the physical requirements of the job and the physical capacity of the worker, worker-related musculoskeletal disorders (MSDs) can result. Ergonomics is the practice of designing equipment and work tasks to conform to the capability of the worker; it provides a means for adjusting the work environment and work practices to prevent injuries before they occur."⁸ "Ergonomics places an emphasis on work practices, biomechanics, work environment, and tool use."⁹

Repetitive motion injury: "Tissue damage caused by repeated trauma, usually associated with writing, painting, typing, or use of vibrating tools or hand tools. Almost any form of activity that produces repeated trauma to a particular area of soft tissue, including tendons and synovial sheaths, may cause this type of injury. Carpal tunnel syndrome, other nerve compression syndromes, and shin splints are examples of repetitive motion injuries."¹⁰

Static posture: "Continuously standing in one position during lengthy surgical procedures, causing muscle fatigue and pooling of blood in the lower extremities. Standing on hard work surfaces such as concrete creates trauma and pain to feet."⁸

Work-related musculoskeletal disorder (WRMD): Conditions that affect muscles, nerves, tendons, ligaments, joints, cartilage, or spinal discs. Work-related musculoskeletal disorders, also referred to as cumulative trauma disorders or repetitive strain injuries, do not include injuries resulting from slips, trips, falls, or similar accidents.

References
1. D Smith, P A Leggat, "Musculoskeletal disorders in nursing," Australian Nursing Journal 11 (July 2003).
2. National Institute for Occupational Safety and Health, Elements of Ergonomics Program, publ 97-117 (Cincinnati: US Department of Health and Human Services, 1997).
3. B Owen, "Preventing injuries using an ergonomic approach," AORN Journal 72 (December 2000) 1031-1036.
4. A Converso, C Murphy, "Winning the battle against back injuries," RN 67 (February 2004) 52-58.
5. "Q&A on RSIs, ergonomics, etc," FAQ Typing Injury, CTD Resource Network, http://www.tifaq.com /information.html (accessed 9 Oct 2005).
6. "Static postures," Iowa State University Department of Environmental Health and Safety, http//www.ehs.iastate.edu/oh/static.htm (accessed 9 Oct 2005).
7. A L Nelson, ed, Patient Care Ergonomics Resource Guide: Safe Patient Handling and Movement (Tampa, Fla: Veterans Administration Patient Safety Center of Inquiry, 2001).
8. "Healthcare wide hazards module: Ergonomics," Hospital eTool, Occupational Safety and Health Administration, http://www.osha.gov/SLTC/etools/hospital/hazards/ergo/ergo.html (accessed 9 Oct 2005).
9. J T Bielecki, "Dimensions of back care: Injuries in health care workers," Occupational Health Tracker 5 (Summer 2002).
10. D Venes, ed, Taber's Cyclopedic Medical Dictionary, 20th ed (Philadelphia: FA Davis Company, 2005).

Resources
National Research Council and Institute of Medicine. Musculoskeletal Disorders and the Workplace: Low Back and Upper Extremities. Washington, DC: National Academy Press, 2001.

Online Resources
"Advancing occupational and environmental health and safety globally," handouts from the American Industrial Hygiene Conference and Exposition (May 2004), http://www.aiha.org/aihce04/handouts/po102courtney.pdf (accessed 9 Oct 2005).
"Handle With Care" ergonomic campaign, American Nurses Association,
http://www.nursingworld.org/handlewithcare (accessed 9 Oct 2005).
"OSH answers: Ergonomics," Canadian Centre for Occupational Health and Safety, http://www.ccohs.ca/oshanswers/ergonomics (accessed 9 Oct 2005).
"A California nonprofit corporation providing information and assistance to the RSI community," CTD Resource Network, http://www.ctdrn.org (accessed 9 Oct 2005).
GMB: Britain's General Union, http://www.gmb.org.uk (accessed 9 Oct 2005).
"NIOSH safety and health topic: Ergonomics and musculoskeletal disorders," National Institute for Occupational Safety and Health, http://www.cdc.gov/niosh/topics/ergonomics (accessed 9 Oct 2005).
National Safety Council, http://www.nsc.org (accessed 9 Oct 2005).

Original approved by the House of Delegates, Washington, DC, March 2006
Sunset review: March 2011