Analysis of physical and physiological workloads of nursing in the surgical center

1 Introduction

The operating room (OR) is the hospital sector where surgical and anesthetic interventions are performed in elective mode of urgency and emergency. The complexity of these procedures requires qualified professionals who are able to adapt to unforeseen situations and the demands of the job [1, 2].

The work processes in the OR result from interdisciplinary practices where nurses, nursing technicians, and assistants share tasks and responsibilities with doctors, anesthetists and surgical instrumentalists. In addition to teamwork, individual factors and stress and pressure scenarios to which workers are subjected favor the rise of diseases and disorders in addition to interfering negatively in patient care [1, 2].

In this context, the nursing team represents the foundation in the work process in the OR being able to act both in management and in patient care [1, 3]. Little valued, nursing professionals are exposed to different workload which are related to itself and to the worker’s body [4].

The workload classified as external materiality are physical, chemical, biological and mechanical which are related to the environment and modify in contact with the organism. Physiological and psychic loads, on the other hand, are identified as internal materiality, as they are associated only with the individual himself and with the involvement of disorders and diseases [3, 4].

During work performed at the OR the physical loads are represented by noise, heat, cold, humidity, lighting, insufficient physical space, small rooms that hinder the movement of people or limit the use of equipment; absence of materials and lack of main-tenance. The physiological loads, in turn, are characterized by the physical effort done by the worker during the performance of activity showing inadequate postures or standing for prolonged periods, wal-king long distances during the working day, and weight handling and lifting whether transferring pa-tients from the stretcher to the operating table or transporting materials [3, 6].

The investigation of workloads requires the concomitant analysis of the work process of the entire staff detailing the interrelationships that exist there for a physical load can also present itself as a psychic load to the individual, corroborating to the wear [5, 7]. The physical and psychological wear that affect the worker results from their actions, the circumstances in which they occur, and the results of these actions, compromising their health [4].

Given the above, it is essential to understand the organization of work considering the flow of patients, professional autonomy, authority and hierarchy relationships, use of technology, in addition to the understanding on labor division [5]. By this applying the principles of ergonomics, the Ergonomic Work Analysis (EWA), makes it possible to study, analyze, diagnose and correct a real work condition [8].

Conducting an ergonomic study presenting solutions to demand analysis contributes to the reduction of costs with occupational accidents and injuries, vulnerability and absenteeism, creating a more comfortable place to perform the task allowing greater productivity [9, 10]. At the OR productivity is ass-essed in the operating room by the rate of surgeries performed, length of stay of the patient in the room, anesthetic recovery, time interval between sur-geries, rate of delay and cancellation of procedures [11]. Cancellations on the day of the operation are valuable indicators that translate ineffective hospital management, and can have significant consequences for public hospitals [12].

In this sense, the investigation through the EWA allows to recognize the situations resulting from the work process that interfere in the health of the nursing professional. Thus, the objective of the study was to identify the physical and physiological workload of nurses in an operating room and their impact on workers’ health, as well as to draw ergonomic recommendations based on the analysis performed and on the literature.

2 Methodology

Characterized as exploratory, observational and descriptive research, the study took place in the operating room of a university hospital between August 2017 and July 2018. The research project was approved by the ethics committee of the Health Sciences Sector of UFPR, under number 2015017272.

The service, considered of high complexity offers care to adult and pediatric patients, including plastic surgery and general procedures, urology, proctology, orthopedic, neurological, cardiovascular, otorhinology and ophthalmology, including transplants. The surgeries are elective, urgent or emergency.

Twenty nursing workers of both genders who worked as room circulators or transport professionals and who accepted and signed the informed consent form were included in the research. Those who did not allow the observation of the work or did not accept to voluntarily participate in the study and did not sign the informed consent form were excluded.

The data collection at the OR was based on the Ergonomic Work Analysis (EWA) which is composed of five stages [13]. Demand analysis consists of identifying the problem that justifies the ergonomic action. This stage comprises the reports and requests from the OR’s leadership and workers. In the next step, task analysis, the functioning of the whole is investigated and an attempt is made to understand the difference between the prescribed work and the one actually performed. The activity analysis, in turn, aims to observe the professional separately, identifying the internal (specific to the individual) and external (related to working conditions) factors that influence him in the work process. From these studies it is possible to trace the diagnosis justifying the issues raised in the demand analysis and propose recommendations in order to solve the diagnosed problem [10, 15].

The demand analysis was carried out on the first visit to the OR in a meeting with the head to present the research project proposal. On that occasion, problematic points of the service were elucidated, thus justifying the study.

Subsequently, the analysis of the task was based on the recognition of the site, observations on the general functioning of the OR and the identification of the prescribed work and the work performed by the room circulators and transport professionals. This information enabled the elaboration of a basic profile of the employees and the elaboration of a semi-structured interview script used in the analysis of the activity which is related to the worker’s behavior in task executions and how it is processed.

The interviews addressed questions about the physical and physiological workload, in addition to covering topics about years of experience, employment, the preference for certain surgeries and the description of the steps and strategies of the task performed. When authorized, the interviews were recorded and transcribed in full.

To analyze the activity a worksheet of observations of the actions was also used every five minutes for a minimum of one hour. We tried to observe the same professional in different situations in order to understand and reproduce the reality of work in the OR.

The circulator’s work was monitored during the surgeries, recording the number of times the worker sat, walked, stood, took notes, provided medical and patient assistance, opened packages, bent over, performed strength movement, exited and returned to the room. The movements that were most repeated during the surgical procedure, as well as complicati-ons, unforeseen events and verbalizations were noted. When possible a photographic record of the materials and the circulator was performed during the task.

The investigation of the work performed by the transport professional occurred after a pick up or delivery of patients to the ward, such as their admission to the OR. Carefully observed the steps and strategies used by workers to perform the task, especially in the transfer of patients, this being the main item. The doubts were cleared during the configurations whenever possible. Table 1 shows the total visits to the OR specifying how the data collection occurred.

For the description of the results the qualitative data was expressed by means of descriptive statistics, from the average, standard deviation and frequency being organized in guiding questions. Based on the results of the investigation, the diagnosis was made and ergonomic recommendations based on the literature were proposed [3, 16].

Twenty nursing workers of both genders participated in the study having an average of 45.7±13.72 years of age, who were assessed through the semi-structured interview and the action observation wor-ksheet. Table 2 summarizes the sociodemographic characteristics and information on the work perfo-rmed by the studied population.

In the analysis of the activity, the work of the circulator was monitored during general, otorhinolaryngological, ophthalmological, orthopedic, vascu-lar, proctological and urology surgeries. It was possible to observe the same worker performing his function in different surgical specialties, the duration of the procedure being variable. While small surgeries lasted up to one hour, the most complex and considered major procedures lasted more than six hours.

Likewise, the investigation with transport professionals took place in several situations taking into account the type of anesthesia that the patient had been submitted to and the way of transferring the stretcher to the bed. Short-term surgeries such as eye surgery, for example, used local anesthetic and the patient performed the transfer by himself. Those who underwent spinal or epidural anesthesia needed minimal help from professionals. However, in more extensive surgeries such as cardiac or proctological surgeries in which there was a need for general anesthesia, workers made a great physical effort to transfer these patients.

3.4 Physical effort X pain

Nursing workers associate physical effort with predominantly standing work postures, the use of lead aprons and the transfer of patients, equipment such as video towers and boxes of surgical material. 80%of the interviewed professionals stated that they made physical effort in the execution of the activity and 70%reported already feeling pain or some discomfort as a result of their work performance. Figure 1 illustrates the amount of material used during an otorhinolaryngology surgery, boxes with weights and variable postures and the effort made by the worker during the performance of the room preparation activity.

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Fig. 1

Photos of workers during the execution of the room preparation activity.

Note the excessive weight of boxes of materials and the most varied postures adopted during the preparation of the room, which are similar to the prevalence of the actions taken during surgeries (Graph 1). Concomitant to this analysis, there is an interrelation of postures during the performance of these activities, along with the main complaints of the worker, with spinal disorders being the most prevalent. Pain and swelling on the legs, muscle tension in the back and headaches and shoulders were other complaints identified.

In addition to what was reported by the participants in our research, the observations of the actions every 5 minutes allowed to verify which movements were most performed during the activity (Graph 1). Graph 1 shows the result of 16 hours of observation of actions during surgeries in different disciplines, showing the physical effort made by the circulator determined by the frequency of movements during work. There is a greater prevalence of the “walking” action followed by the “standing” and “packaging” actions. This result shows that the worker’s physical effort is mainly associated with standing posture and the demands of the muscles of the lower limbs and lumbar spine, these being the main pain complaints among the interviewees (Fig. 2).

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Fig. 2

Actions performed by the circulators during surgical procedures.

Although the patient’s transfer board can be used in order to avoid excessive physical effort by the worker it was used only once during the entire observation period in the OR during transfer of an obese patient.

In this context, the participants were asked about the use of biomechanics for job performance. Al-though some acquired the knowledge during the training, no one uses the precepts and report never having received training from the institution with a focus on transferring patients.

It is known that the practice of physical exercises supports the prevention of a series of diseases, being recommended by several guidelines for at least 30 minutes regularly throughout the week [18]. However, in our survey, only 45%of workers practice any activity, including walking (22.22%), Pilates and walking (11.11%), Pilates and Yoga (11.11%), weight training (22.22 %), dance, (22.22%) and pedaling (11.11%) with a weekly frequency of twice (11.11%), three times (22.22%), five times (44.44%) and every day (22.22%).

The participants in the present study were relatively young, predominantly women, most of whom were nursing technicians working as room circula-tors. It is known that the health of the nursing professional is influenced by the physical and physiological workload. The structure and organization (work schedule, surgery cancellation), lack of surgical mate-rial, failure in communication between the team and inadequate postures adopted during the procedures are some of the factors involved in assistants, technicians, and nurses work process in an operation room.

The study showed that scheduling or canceling procedures involves multiple factors, not being dep-endent exclusively on the organization of the OR, but also on the materials and orthoses and prostheses centrals. In order for the map of surgeries to be validated 48 hours in advance, it is necessary to consider a series of variables: the availability of the room, anesthetist, circulator, material and ICU space. However, this organization may undergo changes in cases of emergency.

In this sense, a study in the United Kingdom classified surgical cancellations as preventable and inevitable factors. Avoidable cancellations corresp-ond to administrative errors and the lack of beds, operating rooms, equipment and professionals to perform the surgeries, coinciding with the factors observed in the OR of the present study. The authors emphasize the ambition of surgeons who plan various procedures, underestimating the period of execution and, in the case of work shared with a multidisciplinary team, delay situations should be considered. The suggestion is that the excessive number of surgeries scheduled by the surgeon and cancellations be regularly audited, in order to resolve the issues for an effective management of the operating rooms [12].

The study by Dhafar et al. [19] evaluated the causes and frequency in which cancellations occurred in 25 hospitals in Saudi Arabia, proposing improvements to resolve the findings. The results obtained are similar to those found by Dimitriadis et al. (2013) and those observed in our research. The authors defend the need to develop strategies in cases where the cancellation is related to modifiable issues, that is, organizing blood at least two days before the scheduled procedures, by rationalizing the surgery list and raising awareness of the availability of equipment and other facilities for performing the surgery [19].

Our study showed the lack of equipment maintenance and the lack of adequate materials and equipment. In addition, nurses are often held accountable when materials are lacking, generating situations of stress and improvisation. Strumm et al. affirm that the activity performed by the nurse must be in line with the hospital’s management and administration in order to solve the problems, whether with the purcha-se or maintenance of materials and equipment [20].

Ambitious surgical planning without considering contingencies and interdisciplinary work was addressed in the studies by Dhafar et al. [19] and Dimitriadis et al. [12] as predictors of the delay in the time of surgery, thus justifying the anxiety on the part of surgeons and the pressure suffered by nursing, as reported by (C2) in our study [12, 19].

Hajdukova et al. [21] state that among the problems of human work are human inclusion in the labor process and the relationship with their work. In our research, there was a difficulty in dialogue and approximation between the younger and older teams due to inexperience in handling the materials and assembling the surgical boxes. On the other hand, there was flexibility in the division of tasks, allowing to contemplate individual characteristics and preferences by certain teams, which is positive from the point of view of physical and mental health.

Thebault et al. [22] showed the impact of work on the health of new and old hospital workers. The authors state that when knowledge is transmitted under pressure, with time restrictions, simultaneously and in competition with the professional’s main activity, it can have physical and mental consequences and harm the collective. The lack of supervision of new workers increases the appearance of health problems and the lack of commitment to work.

The research by Onler et al. [23] verified the communication skills of the multidisciplinary team in the operating room, concluding that communication is better among older workers, more experienced and with more years of work in the same unit [23].

Lee et al. [24] also investigated communication in the OR suggesting that after 11 years of experience the worker’s communication skills are fundamentally improved. The authors explain that trust and respect among professionals are significant predictors of communication accuracy. The results show that an understanding of the environment (for example, presence or absence of trust, respect, equal status and availability of time) is essential before implementing any strategies aimed at improving communication between workers [24].

In the present study, the communication failure was noticed during the observations at times when, for example, the transport professional was instructed to pick up a patient who could not perform the surgery, since the room had already been prepared by the circulator.

The lack of professionals, in turn, was also an issue mainly related to patient transport. Rothstein et al. [25] state that the adequate manpower for the development of the activity is a challenge. The OR should have spare workers to ensure flexibility in unforeseen situations or emergencies. However, the authors understand that the lack of professional results from the institution’s financial restrictions, that is, the payment of workers who are not directly involved in patient care or in the preparation of the operating room is avoided [25]. The same situation was found in our study as it is a public institution with limited financial resources.

Intraoperative efficacy is guaranteed by the availability of equipment and labor, therefore, the supply of materials and instruments is of paramount importance to the management of the OR considering that half of the budget is dedicated to replenishing supplies. For this, Fong et al. [26] argue that unnecessary materials for the operation should remain closed, as they reduce costs simply by eliminating the work of restoring unused items. To judge an item as necessary or not for surgery, the team can estimate the need for instruments from previous cases and carry out a survey of wasted supplies, which were opened and not used. The authors cite that the tracking of materials with barcodes is more effective by continuous monitoring, reducing the operational waiting time, maintaining the accuracy of the material boxes and the workflow [26].

The absence or malfunction of materials and equipment to perform the work is another determining factor in the productivity of the OR. According to the research by Perroca et al. [11] performed in a large surgical center in the state of São Paulo, 17.7%of the causes of suspension for surgeries correspond to human resources and 1.6%to the allocation of material resources and equipment. These factors, in turn, correlate with workloads and, consequently, the quality of care provided to the patient and the worker’s well-being [27, 28].

In accordance with the above, other studies demonstrate that the insufficiency of instruments in relation to the demand for surgeries results in the cancellation of procedures and disagreements among the multi-professional team [29, 30].

The conflict between the team was also investigated in the research by Silva and Alvim [31], who listed the lack of material as one of the causes. Acc-ording to the authors, when it is not possible to perform the procedure for this reason, nurses are constantly charged by doctors [31].

Caregnato and Lautert [32], in turn, investigated si-tuations of stress among the multidisciplinary team during the surgical procedure. Among other factors such as the surgical act itself, the environment and the behavior itself, the authors also point out conflicts related to the lack of materials, creating overload in nurses’ work. In addition, the research showed a higher prevalence of insecurity and aggression among younger surgeons, corroborating the testimonies of our study.

The effort made during the performance of the task is related to pain and both are involved in multifactorial causes. According to Silva et al. [33], in addition to the lifestyle of each individual and the organization of work, the biomechanical, physiological and psychological factors of the activity influence the perception of effort and pain by the worker. In cases of mental and physical overload, there is an exacerbation of the perception of effort and symptoms [33].

During the observation of the surgeries in our st-udy, the circulators in the room spent more time walking alternating with movements of bending down (setting up the table and picking up materials) and strength (supporting the patient and reaching for instruments). It was also observed that shoulder flexion was quite recurrent due to the need to change the serum during procedure and the patient’s transfer at the end. The same was noticed among the transport professionals.

Associations between workers’ pain complaints and physical demands (workloads, repetitive tasks and inappropriate postures) and psychosocial exposures to which they are subjected at work have been extensively studied. Neupane and Nygard [34] investigated physical and mental effort at work and its relationship with the onset and persistence of pain in a four-year follow-up. They concluded the association of physical loads with pain complaints in multiple locations among younger workers, while among older ones the association is with mental effort [34].

As stated by Pasa et al. [35], the poor posture associated with not using the patient’s transfer board, its weight and the repetition of the task can cause spinal dysfunctions. Lee et al., [36] investigated the prevalence of musculoskeletal pain in nurses and its relationship with the use of patient lifting equipment and concluded that the greater availability and use of elevators was associated with the lower rate of pain complaints. Knowing that the movement of patients is a risk factor for musculoskeletal injuries among nursing professionals, it is essential to invest to acquire equipment for the adequate transfer of the patient and in educating the workers.

As in the present study, Ravanek et al. [37] verified the perspectives about low back pain related to the work environment, adding prevention, evaluation and rehabilitation. As stated by Souza et al., [38], low back pain can be associated with inadequate postures during the activity, with excess weight lifting, when it exceeds the worker’s strength, flaws in the organization of work, inadequate equipment and furniture, repetitive work, tension and demand for productivity [38]. Inadequate postures and movements overload the musculature, generating tension and consequently the pain and discomfort in the musculoskeletal system. Long journeys decrease blood circulation and can lead to an inflammatory process [14] and consequent muscle shortening and limitation of muscle and joint function [39].

Ribeiro’s integrative review [40] showed that continuing education in the training of OR nurses is of interest to the professionals themselves, in addition to being essential for work practice. The study mentions distance learning (DL), videos, films, group dynamics and simulations as a training option. Then, the debate among professionals associates theoretical and practical knowledge [40].

Considering low back pain as the main complaint in our study, the systematic review by Miculis et al. [41] points out the mechanical factors related to inadequate postures and associated with muscle deficiencies. In this case, physical activity, posture correction and biomechanics training are oriented as treatment and prevention of dysfunction. In addition, identifying the occupational factors that led to its emergence is essential for a correct approach [41, 42].

5 Diagnosis and recommendations

After investigating the nursing work at the OR following the steps of analyzing demand, task and activity, a diagnosis was obtained in order to propose recommendations. Through this the results of the research and improvement proposals were presented to the participants at the end of the study. Table 3 summarizes the diagnoses and recommendations proposed based on the literature [3, 40] after investigating the work at the OR.

The nursing worker is exposed to different physical loads such as noise, insufficient structure and the absence of materials and the physiological loads represented by inadequate postures and weight lifting during the execution of work in the OR. In our study, the lack of materials and maintenance between the physical loads and the physical effort performed during the activity related to the physiological loads prevailed. As verified, the adopted postures during the observations and the prevalence of physical effort and pain indicate that the physical and physiological workloads negatively interfere in the worker’s health. In addition, the prevalence of physical inactivity among the participants of our research as an adj-unct to the health-disease process at work. In addition, organizational factors may be acting against health and safety.

Conflict of interest

None to report.