Work-related musculoskeletal complaints among haemodialysis nurses: An exploratory study of the work situation from an ergonomic perspective

2.1Research ethics

The study protocol was approved by the Regional Ethical Review Board in Uppsala (registration number 2017/229). All of the participants received written information about the aim of the study and its procedures in advance. The information was repeated verbally at the time of data collection. All nurses participated voluntarily.

2.2Study population, sample size and context

To appraise the work environment and explore any potential hazards that could lead to the development of musculoskeletal complaints among haemodialysis nurses, 19 nurses (17 females) were observed at five haemodialysis centres in Sweden. Additionally, 2–6 nurses from each centre, together with the observer, participated in a reflective discussion concerning ergonomics in the workplace and work-related musculoskeletal complaints. The three most common haemodialysis machines in the country were used for the haemodialysis treatments. Haemodialysis treatments were performed on 22–54 patients 3–5 times per week, and each treatment lasted about four hours. During a shift, the 6–10 nurses working in the centre were divided into 2–4 teams that cared for 14–26 haemodialysis patients. The patients were located in 3–8 treatment rooms. Since there were nurses training to be haemodialysis nurses at the time of the data collection, there were more staff than usual. The observed nurses had a mean age of 45.3 years (SD 10.9, range 28–65). They had worked as a nurse for an average of 16.3 years (SD 9.3, range 3.5–36) and as a haemodialysis nurse for an average of 9.2 years (SD 8.0, range 0.5–25). The rate of full-time employment at the time averaged 90.5 % (SD 10.3, range 80–100). Of the 19 observed nurses, 10 reported that they experienced daily work-related musculoskeletal pain from their hands, fingers, and wrists.

2.3Data collection

Non-participant observations, reflective discussions and reflective notes documenting the haemodialysis nurses' work components were used throughout the haemodialysis process to collect the data. In the non-participant observations, a single observer (first author) gathered data regarding the physical setting, the participant’s activities and interactions, frequency and duration of performed activities, and postures used in completing the various tasks. Accordingly, the observer did not participate in the care activities to prevent alterations in the working conditions, but was present to take notes about what was happening and how the nurses acted during the work activities. The observations were, however, somewhat more attentive to manual activities that are known to expose workers to an increased risk of musculoskeletal injuries in the distal upper extremity [11]. The observations were conducted during the daytime shift between 07:00 and 15:00 for three consecutive workdays at each centre, which resulted in a total of 112 h.

Reflective discussions were initiated based on what was observed during the observations to gain an understanding of what the nurses experienced as something that could have an impact on musculoskeletal complaints. The reflective discussions were conducted with the observed nurse and also with any colleagues involved so they could give input from their perspective in regard to interaction, support, working positions and body language/movements during the work situation and/or work tasks. The discussion was based on how the situation affected the nurse’s posture, body language and the workspace. To gain clarity regarding the work procedure and potential hazards, the observer asked reflective questions that added to the discussion. Examples of reflective questions are: Please describe your experience of that component of the procedure in regard to workload. Please describe how you perform that component of the procedure. I can see that you need to use some effort to perform that component of the procedure, how would you rate the intensity of the effort you have to apply using this scale (Borg CR-10 scale)? An example of a more specific reflective question asked is: Which part of your hand/fingers do you think you are straining when you connect and disconnect the bloodlines?

Reflective notes documenting the researcher’s personal reflections, experiences and progress in the field were made by the observer who is a registered nurse with substantial experience in haematology and nephrology nursing, but not in the haemodialysis setting. The observer has good knowledge of the musculoskeletal system, its functions and diseases. She is also an expert in how to make adaptations in the workplace that can lower the risk for health problems and accidents as she has regularly taught these subjects the past 15 years at a university. However, this was the first time she systematically collected ergonomic related data. The field notes were made while still on location at the haemodialysis centres and concerned observational strategies, ergonomic challenges during haemodialysis procedures as well as personal experiences and emotions. The reflections focused on the ergonomic challenges and the differences between the described perceived tasks and the observed execution of the tasks with the haemodialysis equipment.

The field notes and reflections consisted of written descriptive notes. At the end of the observation day, the notes were read and reread, and additions were made as needed. They were then read again to ensure the content reflected the observed components of the haemodialysis procedures as well as how each task affected the nurse from an ergonomic perspective.

2.4Data analysis

The analytic goal was to integrate the collected data by intentionally merging the findings from the observations, reflective discussions and notes in the results to expand the understanding of the haemodialysis nurses’ work situation from an ergonomic perspective. At first, the data from each centre were analysed separately in order to find topics and codes meaningful to the aim of the study. In this process, the transcribed data were read and compared several times. Thereafter, the sets of topics and codes from the centres were compared and contrasted in a matrix to explore in which way the findings from the observations, discussions and notes confirm, disconfirm, qualify, or expand each other. A simplified illustration of the analysis matrix is presented in Table 1. Narrative presentations were finally generated from the matrix comparisons to display the integrated results.

3.1Activities with increased risk of work-related musculoskeletal complaints

Eight work tasks (Table 3) believed to increase the risk of developing work-related musculoskeletal complaints were identified. When starting the priming procedure, the nurses described different types of musculoskeletal complaints/symptoms in their fingers, hands, wrists and shoulders depending on the design of the dialysis machine used. From the observations, the priming procedures were accomplished in a standing position with short forward bending sequences that lasted 1–2 s. The degree of bending depended on the nurse’s height. The observations also revealed that when connecting and disconnecting the bloodlines and the dialysate inflow and outflow hoses to the dialysis filter, there was a resistance that required greater hand strength. When the disposable bloodlines were screwed onto the filter, cracking sounds were audible. Depending on the position and angle of the hand while assembling the lines, physical demands were placed on different parts of the hand, i.e. the thumb and scaphoid joint, index finger, middle finger, wrist or metacarpals. Several nurses told that they experienced fatigue in their fingers and in the musculature and tendons on the back of their hand after priming several machines. They said that it was related to their having to grip and pull back with two fingers (index and middle finger) against the palm of their hand on the dialysate connectors to disengage them. Here the nurses also described how the calcium content of the water contributed to the difficulty. With limescale, the resistance was increased when attaching and detaching the connectors. In addition, the nurses told how the removal or tightening of protective caps and the opening of packages containing disposable materials was physically demanding for their fingers.

A well-functioning vascular access is necessary to connect the patient to the haemodialysis machine. The accesses used were either a central venous catheter (CVC), arteriovenous fistula (AVF) or arteriovenous graft (AVG). The accesses were checked before the start of the dialysis treatment with a flushing process. At the different dialysis centres there was a variation in the number of times the access was flushed with normal saline. An observed 1–15 flushes per lumen were performed before the bloodlines from the machine were connected. Flushing generated a somewhat hard physical demand on the thumb, index finger and middle finger of the hand being used. This flushing process is shown in Fig. 2.

Fig. 2

Reconstruction of the flushing process performed on the central venous catheter before connection to the bloodlines. Blood and heparin are aspirated from the central venous catheter before flushing the lumen multiple times with 0.9% normal saline.

Connection of the bloodlines to an AVF or AVG was accomplished by a nurse working alone or together with a colleague. When connecting the bloodlines to a CVC (Fig. 3), the nurse was in a standing position, often leaning slightly forward about 130° towards the patient. This was also performed alone or together with a colleague. When this was carried out by two persons, the assistant would help the nurse with e.g. filling the normal saline syringes and handling the gauze pads with disinfectant in order to maintain the most aseptic technique possible. When the nurse performed this procedure alone, more planning and preparation was required so that the necessary items were within reach. Work done alone generated working positions with more twisting of the back and shoulders as well as stretching of the arms in order to reach the materials being used, than work done in pairs.

Fig. 3

Connecting the bloodlines to a Central Venous Catheter.

The nurses perceived that the size and type of material used for the clamps on the bloodlines made a difference in how stiff they were, and thus required more or less force when opening and closing them. When the clamps were larger, the nurses complained of an increased musculoskeletal load and strain on their thumbs and fingers. Examples of the clamps are shown in Fig. 4. Sometimes a two-handed grip was required to close the clamps. After starting the haemodialysis treatment, all of the bloodlines and dialysate hose connections were checked several times. Properties in the bloodlines change with the change in temperature from the warm blood. Because of this, the nurses needed to retighten a majority of the connections multiple times during the dialysis to ensure they would not leak. The nurses experienced a strain on their fingers and wrists when doing that.

Fig. 4

Examples of typical clamps on the bloodlines.

The electronic monitoring of the dialysis treatment could be programmed so that the nurse must log in to change the settings on the machine. To log in, a nurse would have to raise their arm to enter their password on the touch-screen monitor. The number of taps on the screen depended on how long the password was. During one nurse’s workday (07:00–15:00), 453 taps on the screen were counted. The nurses experienced this as tiring for their shoulders and neck. Having to hold their arms up over shoulder height to work on the screen often led to perceived numbness or pain in the trapezius muscles and arms.

After the dialysis treatment was concluded for patients with an AVF or AVG, compression was needed to form a clot and stop the bleeding at the cannulation sites. This was usually performed by the nurse, and required steady pressure applied by 2–4 fingers. The applied pressure was not hard, but the static pressure on the AVF/AVG was still stressful for the body since it took about 5–20 min. The nurses experienced a strain was put on their fingers, arms and shoulders when applying pressure on the cannulation sites. They also perceived a strain was put on their backs due to the twisted position they had to assume while sitting or standing. The need to have physical access to the cannulation sites reduced the possibility for an optimal ergonomic body position.

Cleaning after a completed dialysis treatment involved working in cramped spaces between the dialysis machine and e.g. the bed, treatment chair, walls and water pipes. The nurses’ work positions varied from having to stand on their toes to having to squat in order to reach everything. The dialysis machines have protruding parts e.g. knobs and holders, which could cause damage to the nurses’ hands and skin on their wrists.

The gathering of materials and supplies could give pain in different parts of their hands depending on the form of the packaging and how it could be lifted out of the shipping carton. A three-finger grip was needed to unpack filters no matter if they were upright or laying down. This work also included moving large and small containers of concentrated dialysate unless a central delivery system existed. Consumable materials needed to be moved and distributed from the storage room to the dialysis rooms. Even the sorting of packaging materials for recycling was describe as physically demanding.

The physical space surrounding the patient during the dialysis treatment could be quite limited. There were often many dialysis machines in the same room. The design of the premises and the location of the equipment in relation to the patient’s blood access could require the repeated movement of the dialysis machines during the day. Shifting the machinery or other equipment depended on whether the patient was in a bed or treatment chair and on which side the patient had their access. However, the observations revealed that the routines for moving equipment varied substantially in the different dialysis centres. Machines at one centre were moved as needed for each patient, while machines at other centres were only moved if they needed service. The nurses said that the machines were physically heavy to move. The connections that are required for the machine to function e.g. power cords and water hoses made movement more difficult. These movements were often done in unfavourable positions that resulted in a noticeable strain on the torso and back muscles, and in some cases, even the arms.