Hospitals must look beyond musculoskeletal disorders for ergonomics compliance

Programs may confront repetitive stress disorders

Patient lifting may be the primary risk of musculoskeletal disorders (MSDs) among health care workers, but the proposed federal ergonomics standard may compel hospital employee health professionals to confront a less obvious source of injury — repetitive stress disorders among clerical and laboratory workers.

About 6,400 hospital employees suffered from repetitive stress disorders in 1998, according to the Bureau of Labor Statistics. Since hospitals are one of the largest employers nationwide, the industry ranks fourth in the number of repeated trauma disorders. (The majority of repeated trauma cases are in the meat packing and manufacturing industries.)

The U.S. Occupational Safety and Health Administration’s (OSHA) proposed ergonomics standard, which is the focus of a final round of hearings in May in Washington, DC, requires employers to establish a program to eliminate work-related MSDs. A single reported MSD would trigger either a "quick fix" or a full-blown ergonomic analysis.

What kinds of repetitive stress disorders occur in hospitals? Consider the plight of the lab worker. He or she leans over a microscope for hours each day and tightly grasps a pipette. The possible results: neck pain, back pain from poor posture, and wrist pain from repetitive stress.

Or consider the aches of clerical workers. They may pound on computer keys for hours at a time. This kind of activity can result in cumulative trauma to the wrist.

"You get into a problem when any part of your body is out of proper alignment for long periods of time," explains Judith S. Ostendorf, MPH, RN, COHN-S, CCM, clinical instructor with the occupational health nursing program at the University of North Carolina School of Public Health in Chapel Hill. (For information on a tool to evaluate or design an ergonomics program, see editor’s note at the end of this article.)

An uncomfortable chair or a work surface that is too high or too low can contribute to a problem. In a good ergonomics program, employee health professionals evaluate work stations and make corrections even before employees complain of pain, says Guy Fragala, PhD, PE, CSP, director of environmental health and safety at the University of Massachusetts Medical Center in Worcester and a leading ergonomics expert. (For more information on proper computer workstation positions, see box on p. 52.)

"If someone is doing a task for a good part of the work day, repetition becomes a big part of the evaluation," says Fragala. "If the work station isn’t designed properly and people are in poor postures, that can be a risk factor as well."

How many repetitions are too many?’

Cumulative trauma disorders (also called repetitive stress injuries) are a controversial aspect of the proposed ergonomics standard. The National Coalition on Ergonomics, a Washington, DC-based coalition of business groups opposed to the standard, asserts that not enough is known about what causes such injuries. Citing similar concerns, the American Hospital Association signed on to the coalition’s comments.

"In a very general sense, there’s a link between activity and injury, but we don’t know the specifics," says coalition spokesman Al Lundeen. "That’s what we need to know to regulate. We don’t know how many repetitions are too many. We don’t know how heavy a lift is too heavy. We don’t have a clear definition of what an awkward lift is."

In an opening statement at the first hearing on the ergonomics standard, Marthe Kent, head of OSHA’s regulatory program, acknowledged that studies continue to shed light on repetitive stress. "Although OSHA agrees that all the answers are not in and that more research is always helpful, there is more evidence on work-related MSDs than there is for any other occupational injury or illness, and the research base is growing by leaps and bounds," she contended.

Kent also noted that workers with carpal tunnel syndrome lose an average of 25 work days per year, with some losing six months or more. (For more information on the initial OSHA hearing, see related article above.)

Experts on ergonomics have identified factors that contribute to cumulative trauma disorders and ways to lessen the risk of injury.

While repetition of motion is clearly a major risk factor, it interacts with other factors such as duration and force, says Ostendorf. With excessive force, circulation to the muscle decreases and leads to muscle fatigue, she says.1

The risks aren’t solely related to the job tasks. Some workers will apply more force to do the same activity, she notes.

"It depends on their habits," she says. "Sometimes you notice someone who inputs data on an adding machine, and they use a very light touch. Other people pound on the keys. The pounding puts tension on your tissues."

Other risk factors relate to age and gender. Women are more likely to develop carpal tunnel syndrome and similar musculoskeletal problems that have been linked to repetitive motion. Older workers may be more at risk simply because they have been doing the same tasks for a longer time.

Smokers also are more susceptible because their blood carries less oxygen than that of non-smokers, she says. "The way your muscles, tendons, and nerves stay healthy is from a good blood supply," says Ostendorf. "When there’s not as much oxygen in the blood flow, then that freshly oxygenated blood doesn’t come to the tissues to help them stay rejuvenated."

The ergonomic "fix" for clerical or lab workstations is often simple and inexpensive, says Fragala. In some cases, correction involves minor adjustments and a bit of education about proper posture.

"Make sure work station heights are appropriate and that people know how to adjust their chairs properly," he says. "For people who are going to be entering data, how can you best arrange your work station so you’re in the best posture possible?"

For example, clerical workers shouldn’t turn their necks in unnatural way to review documents. They also may need keyboard drawers or wrist rests.

Debra Campbell, an occupational and environmental safety officer with the University of Massachusetts Medical Center, evaluates work stations upon request by employees, their supervisors, or employee health professionals.

"We’ve been very successful in helping folks redesign their workstations so the pain is usually eliminated in a short period of time," she says.

In one case, the "repetitive stress" Campbell identified was also linked to improper lifting. Sterile supplies at one hospital were organized by manufacturer without taking into account the weight of the containers. Sterile supply staff and OR nurses were pulling kits weighing 30 pounds or more off high shelves.

After reorganizing the supply room, the staff could pull heavier items from shelves at shoulder or waist level.

Sometimes, the problem isn’t actually repetitive motion; it’s lack of motion, says Fragala. Sitting in the same posture for hours can lead to muscle strain. Again, the simple solution is to encourage workers to take regular breaks, even for just a few minutes.

Employee health professionals can determine whether they have a brewing problem with repetitive motion disorders by tracking and analyzing injury rates. Because the ensuing musculoskeletal problems, such as carpal tunnel syndrome, can be costly and disabling, Fragala endorses a proactive approach of analyzing work stations and responding to more minor symptoms, such as discomfort and fatigue.

"The key is not to let the situation develop to a serious stage," he says.

[Editor’s note: Judith Ostendorf created a data collection worksheet for evaluating occupational health management in an ergonomics program to enable employee health professionals to benchmark against an ideal program design or create a new program. The tool has been reviewed by OSHA’s Office of Occupational Health Nurses and is available free of charge from Ostendorf at (919) 966-2597 or]


1. Ostendorf JS, Rogers B, Bertsche PK. Ergonomics: CRD management evaluation tool. AAOHN J 2000; 48:17-24.