Ergonomics

Function

Successful application of ergonomics can reduce the chance of illness and injuries, improve worker productivity, and increase satisfaction in the workplace. Conversely, it can often lead to increased work-related musculoskeletal disorders (WMSDs) if applied incorrectly. WMSDs are disorders of the musculoskeletal system due to work environments and/or when a pre-existing musculoskeletal disorder worsens due to work conditions or risk factors inherent in the workplace. Examples of workplace risk factors include jobs requiring repetitious, forceful, or persistent use of the upper extremity, frequent lifting, pushing, pulling heavy objects, or maintaining prolonged uncomfortable postures for an extended period.[2]

Issues of Concern

The reduction of WMSDs is often considered the largest concern for ergonomics. Back, neck, and upper extremity injuries are some of the more common WMSDs, with studies demonstrating correlations between certain specific movements and combination of movements within work (lifting, twisting, prolonged walking/standing, squatting, prolonged standing, and repetitive motions) placing individuals at an increased risk for developing WMSDs.[4][5] 

The extent and type of WMSD vary widely depending on the individual and method of injury, most commonly being general discomfort and swelling/stiffness cited throughout the body; varicose veins, postural imbalance/associated weakness, and discomfort in knees/ankles/hips within the lower extremities; spondylosis, and radiculopathy in the back; and De Quervain's tendonitis, Carpal Tunnel Syndrome, and shoulder impingement syndromes in the upper extremities.[6][7][8] 

Proper implementation of ergonomics has been repeatedly proven to reduce WMSDs across multiple fields of work, thus reducing the number of associated lost workdays and loss of wages and reducing associated potential psychosocial disorders that can be developed post-WMSDs.[9]

Implementation of ergonomics is fluid depending on workplace requirements as well as the individual completing those tasks, with females often having increased risk for WMSDs compared to their male counterparts due to smaller stature and decreased physical strength output as well as instrument size/design being geared to male stature.[6][10]

Psychosocial factors require attention when addressing ergonomics as well, due to their impact on ergonomics itself and the potential fallout from WMSDs. Studies have demonstrated links between WMSDs and psychosocial work factors such as job stress, work organization, and social support. These factors can impact the ergonomic performance of an individual, thus impacting their risk of WMSDs.[11][12] 

Links have also been associated with the development of psychosocial disorders, including depression and maladaptive pain response, with the potential to lead to disability if not properly addressed following WMSDs.[9] Fear of movement (FOM) is another factor that can negatively impact an individual's receptivity to ergonomic education and place them at a higher risk for developing WMSDs.[13] This is important to note from a preventative standpoint for medical professionals within their care, but also to better serve their patients' needs.

Clinical Significance

Occupations requiring repetitive actions, heavy lifting, or prolonged awkward positioning increase the risk of developing WMSDs. Some of the most at-risk occupations include drivers, maintenance and construction, agriculture, and healthcare workers.[3][14] Within healthcare, those most often cited with increased risk for WMSDs include surgeons, nurses, therapists, and dentists, with specific ergonomic recommendations for each as follows.

Surgeons

Surgeons are often subjected to long hours standing, awkward positioning, and repetitive use of UE instruments, increasing their risk of postural fatigue and repetitive use injuries. Below are ergonomic accommodations that can be completed by surgical staff to reduce the risk of developing WMSDs:

• Maintain a neutral spine position with the muscles relaxed while taking brief moments every 10 or 15 minutes to be aware of body alignment while making the appropriate adjustments to reduce discomfort. To minimize the stress on joints, grip surgical instruments with a light hold, alternate hands when completing easier, repetitive tasks or evenly apply pressure when squeezing bottles using all the fingers instead of just the thumb/index finger.[15]
• Head and neck position (as close to neutral with no more than 15 degrees flexion recommended, with monitoring the use of loupes and headlights as the extra weight tends to exacerbate cervical flexion).
• Position monitors 1 meter in front of surgeon and declination of 0 to 15 degrees.[16]
• Adjust table position to allow elbows at 90 to 120 degrees to ensure proper alignment of the back. Additionally, adjust and readjust the patient pre and intraoperatively to maximize ergonomic positioning and alignment.
• Incorporating stretching routines, including full routines pre/post-op or intraoperative "micro-breaks," have been shown to reduce pain while not increasing operative time.[16]
• Ensure the chair has adequate spinal support for those utilizing chair and foot pedals. Position foot pedals approximately hip-distance apart, at the same height with even distribution of pressure in both feet. Place chair at a comfortable height with knees bent close to or slightly less than a 90-degree angle.
• If utilizing a microscope, use ocular extenders to prevent leaning forward. Take periodic breaks (every 10 to 15 minutes) from using the microscope and from focusing on a target at a distance when looking away from the microscope. To reduce stress on joints, utilize both hands when adjusting the microscope.[15]

Laparoscopic approaches have been employed as a minimally invasive method to complete common procedures. Benefits of laparoscopic surgery include reduced postoperative recovery times and postoperative infection rates.[17] However, one of the biggest drawbacks to laparoscopic surgery is the limitations in view and angles for surgeons compared to an open approach. Coupled with maintaining prolonged static postures, which can increase lactic acid build-up in the muscles and tendons, laparoscopic procedures can have adverse ergonomic outcomes on surgeons. The optimal positions of the surgeon, table, monitors, and trocar placement are all important variables to improve the ergonomics involved in laparoscopic procedures.[18]

Nurses

Nurses have a high prevalence of WMSDs, with operating room nurses having a higher prevalence. Nurses in the operating room are subjected to the same ergonomic risk factors as surgeons, with additional issues arising with those nurses caring for patients requiring increased patient handling (often at an unmatched weight proportionate to the nurse completing the transfers). Studies have also noted nurses have an added layer of psychosocial risk factors regarding WMSDs due to lack of control and autonomy in their tasks, which has been cited as a risk factor for WMSDs.[19] 

In addition to the surgical ergonomic suggestions for those applicable, nurses can reduce their risk of injury by implementing the following ergonomic tactics:

• Utilizing proper supportive footwear and antifatigue mats and use of stockings to reduce edema and promote blood flow.
• Utilizing proper transfer ergonomics, including use of lifting equipment when appropriate, gait belt use, multi-team transfers, and use of drawsheets, sliding boards, or air-assisted transfer mattresses.[20][21] Before completing transfers, positioning should be completed, including locking of brakes on gurney/bed/wheelchair, adjusting bed height for ease of transfer being completed, positioning receiving transfer surface to the proper side of the patient, ensuring the patient has proper footwear (no-slip) and ensuring instruction has been provided to the patient so they can assist in the transfer as much as possible.[21]

Therapists

In addition to nurses, therapists are also often in the role of patient handling, positioning, and transferring, with the same ergonomic principles previously listed for nurses applicable to their field as well. In addition to this, physical therapists are noted to have increased risk for WMSDs due to providing manual therapy to patients, placing increased workload on the providers' upper extremities (particularly wrists/hands).[22] Ergonomic suggestions to reduce these injuries not previously listed include:

• Providing proper staffing allows for distributing workload and utilizing support staff as needed.
• Modification of treatment plan to include alternative treatments and utilizing equipment to reduce manual contact required to achieve therapeutic benefit.[10]
• Ensuring practitioners have access to means to promote physical fitness within themselves as a preventative measure.[22]

Dentists

• Ensuring proper placement of adjustable light and instrument table.
• Opting for the most ergonomic tools (those that are adequate in diameter curved, and with knurling or grooves allow for the best friction with the least amount of force).
• Opting for automatic instruments compared to manual to decrease the force applied to hands and wrists.
• Avoid using retractable and coiled hoses as the tension when the hose is stretched is transported to the wrist and arm.
• Considering positioning the patient horizontally.[2]
• Emphasis on correct seated posture (especially utilizing hip tilt when completing seated forward bending as often required to maintain lordotic curvature).[23]

Though everyone will have different ergonomic requirements based on their stature, job requirements, and equipment use, basic principles of ergonomics common across many fields are essential for clinicians to know to better educate their patients as a treatment and preventative measure for WMSDs. The basic principles that follow can help to reduce the rate of WMSDs across all occupations:

• Decreasing weight handled when lifting through team lifts, use of equipment, or portioning the load into smaller/lighter containers.
• When lifting, ensure the object being lifted is as close as possible to the body (ideally between the knees), maintain an erect back posture, and squat.
• Maximizing time allowed for lifting heavy objects and rotating heavy tasks.[1]
• Allowing for frequent rest breaks.[5][6][19] 
• Seated positions that provide adequate support for the spine, upper, and lower extremities, including proper lumbar support, maintaining wrist angle of less than 10 degrees extension, and angling screens between 10 degrees and 30 degrees).
• Using properly fitting instruments (dependent on hand size and preferred hand use), utilizing power tools as opposed to manual where appropriate, and ensuring proper size and texture of handle to maximize grip strength (50-75mm diameter often recommended made from a smooth and compressible gripping surface).
• Use of antifatigue mats, properly fitting and supportive shoes, and compression stockings to promote proper blood flow.[4]
• Ensuring properly fitting gloves to avoid increasing risk for carpal tunnel syndrome.

Other Issues

Another issue for proper ergonomics to occur (especially in the healthcare sector) is the lack of proper equipment required to reduce the workload on employees. Overexposure to heavy lifting tasks and prolonged posturing has been cited as a major contribution to WMSDs across the general working population due to the inability to maintain proper ergonomic form secondary to fatigue.

Lack of assistive equipment, coupled with inadequate personnel to complete safe transfers and pressure to complete transfers quickly for increased productivity, often results in poor ergonomic measures and leads to increased incidence and severity of the injury.[20][16]

Enhancing Healthcare Team Outcomes

Interprofessional support and communication are vital to developing, implementing, and maintaining proper ergonomics and their associated factors in the workplace. Studies point to multiple associated factors that can impact ergonomic stature and thus WMSDs, including autonomy and support at work, gender resulting in a strength-job mismatch, and proper support staff and equipment.[19][24][20] 

Level 1 studies have demonstrated the importance of having a multifaceted approach to ergonomics within the workplace, including equipment, ergonomics, employee training on patient handling, and exercise programs for workers in healthcare.[25]

Safe Patient Handling and Mobilization Programs (SPHMs) have been proven through level 1 studies to be an effective means to incorporate proper ergonomics to increase the safety and reduce injuries of both clinicians and patients within the work field.[26] These programs need to be developed in a team setting to ensure the perspective and needs of all active members are addressed and require the medical team to be active in assisting one another during the patient care tasks to provide the safest care for both the patient and clinicians involved.

One study noted that patients report feeling safer when staff uses safe transfer techniques than those who used poor techniques, which translated to improve quality of patient care (in addition to the already mentioned safety benefits for patients and clinicians alike).[27] Level 3 studies have also noted the need for proper staffing to allow for adequate breaks from ergonomically burdensome tasks to prevent excessive fatigue and burnout, which ultimately leads to an increased risk of injury.

A recent level 5 study following the surge in mass fatality handling secondary to the COVID-19 pandemic demonstrated the need for not only implementation of ergonomic training for staff but the benefits of having an SPHM team in place at facilities to assist in situations where singular transfers are not safe, or patient size requires multiple individuals to transfer without injury.[24]

Level 2 studies have also demonstrated the importance of arranging the workstation to meet physical, ergonomic requirements for those participating in office work which is important to note only for its transferability to the stations that clinicians spend time documenting at but also for the need for many patients seeking treatment. It is important to remember that many of the same ergonomic principles that should be applied to the healthcare workers' daily tasks can be used as educational pieces to better serve patients faced with similar positional and task components within their own line of work.[28]

Nursing, Allied Health, and Interprofessional Team Interventions

In addition to the multiple individual actions that can be implemented to increase the use of ergonomics within specific and general workplace settings, there are several interventions to promote proper ergonomics. Implementing a workplace strengthening program or using physical therapy centered on strength training has been demonstrated to reduce the risk of WMSDs for those individuals with physically demanding jobs.[5][29] 

Ergonomic training programs for employees have been proven beneficial at reducing poor posturing and frequency of WMSDs but have also noted difficulties concluding the best method and means for completing education for personnel retention and application.[30][31] In addition, ensuring that the task is matched to the physical capacity of the individual performing (and altering assigned tasks if not) is a crucial component to ensure worker safety. This is particularly critical for females as they tend to have a higher rate of WMSDs.[3][6][10] 

Support for coworkers is another component required to provide adequate support when tasks require increased personnel to complete safely and due to the impact interwork relationships have on the perception of overall health and well-being, which has been shown to impact the perception of pain.[11][12][32][24]

Nursing, Allied Health, and Interprofessional Team Monitoring

In the healthcare setting, lack of data in specialty settings and for females is one of the biggest hindrances for ergonomic implementation. Continued efforts are needed to establish sound data for the ergonomic needs and implications for both areas, especially as more females continue to enter the healthcare field in recent years. This is particularly important not only for the health of the individual clinicians but also due to the economic burden resulting from WMSDs. 

WMSDs have been cited as the most expensive work-related disability. As females are already at an increased risk of sustaining WMSDs coupled with a lack of current recommendations specific to their stature and physical ability, the need for ongoing research and recommendations is critical.[16][33] 

Moreover, SPHM programs that are established require constant updating and review to monitor retention of knowledge and monitor burnout, which is often a factor in the healthcare workers' satisfaction, which they do not mention or report willingly.[16] 

The home healthcare sector faces extensive ergonomic limitations due to the fluidity of the work environment, including lack of control and ability to set up an ergonomic workstation, increased physical and mental stress of travel to the patient's location, and difficulty in staffing shortages which increase demand on the individuals. Continued focus on worker and patient safety, including prioritizing adequate time to complete physically demanding tasks over productivity, is critical, especially in the home setting.[32]