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Work-Related Musculoskeletal Disorders of Perioperative

Personnel in the NetherlandsPAUL MEIJSEN, BED, MA; HANNEKE J. J. KNIBBE, MSC, RPT

Editor’s note: In the Netherlands, person-nel working in the OR typically are notnurses. Personnel who want to work in thescrub, circulating, or first assistant rolesundertake a three-year education program,after which they become operatieassistenten(singular: operatieassistent). This term hasbeen used throughout the article to clarifythat these OR personnel perform many ofthe duties that perioperative nurses performin the United States, but they are not RNs.

Approximately one-third of allcases of sick leave for healthcare workers are related to

musculoskeletal disorders (MSDs) orig-inating in the neck, shoulders, andback. The causes of these disorders aremainly related to the high exposure toheavy physical loads involved in workin health care.1 The percentage of sickleave among hospital staff members inthe Netherlands was 7.8% in 1999, andthus considerably higher than the meanfor the working population as a whole(ie, 5.4%).2 This finding resulted in anagreement between the Dutch Ministryof Social Affairs and Employment; theMinistry of Health, Welfare, and Sport;and health care employers and unionsto try to reduce the incidence of sickleave and the number of worker’s com-pensation claims in hospitals and createa safe and pleasant working environ-ment for hospital staff members.

Earlier studies of perioperative per-sonnel have focused mainly on the caus-es of physical pain and measures for pre-vention.3-6 The purpose of this study wasto gain insight into the nature and scopeof MSDs. It is necessary to gather epi-demiological information on the natureand scope of MSDs to ascertain whetherthey are more prevalent in perioperative

settings than in the general population.Based on this information, causes can beexplored and preventive measures can besought and implemented. This study alsoprovides reference data that could be ofuse in testing the effectiveness of preven-tion policies.

Two specific research questions anda third more general research questionwere asked.• What is the prevalence of MSDs

among operatieassistenten in theNetherlands?

• What percentage of sick leave can beattributed to MSDs among oper-atieassistenten in the Netherlands?

• What causes and possible preventivemeasures do operatieassistententhemselves perceive with regard toMSDs?To answer the research questions, the

APPROXIMATELY ONE-THIRD of all cases of sickleave for health care workers are related to muscu-loskeletal disorders (MSDs) originating in the neck,shoulders, and back.

A CROSS-SECTIONAL MULTICENTER SURVEYbased on the Nordic Questionnaire for Analysis ofMusculoskeletal Symptoms investigated the natureand scope of MSDs among Dutch OR personnel.

THE THREE-MONTH PREVALENCE RATES forMSDs in OR personnel were found to be high com-pared to MSDs in the general population and com-parable to rates in other strenuous professions inhealth care, industry, and construction. The causes ofMSDs that participants mentioned were summarizedinto four main categories: prolonged standing, awk-ward postures, lifting and pushing; and climacticconditions. AORN J 86 (August 2007) 193-208. © AORN, Inc, 2007.

ABSTRACT

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194 • AORN JOURNAL

researchers chose to use a self-administeredquestionnaire to efficiently gather anonymousresults that are generalizable at a national level.7

DESIGNThe study was a cross-sectional multicenter

survey. Data were collected on a one-timebasis in 16 operating departments in 16 hospi-tals, by means of a questionnaire consisting ofclosed and open-ended questions.

INSTRUMENTThe questions used in this study were based

on the Nordic Questionnaire for Analysis ofMusculoskeletal Symptoms.8 This question-naire has been tested by other authors andfound to have good reliability and validity.8,9

There is also abundant reference materialavailable about the instrument.8,9 The sametypes of questions have been asked in ergo-nomic studies for more than 15 years. Thisform of questioning avoids diagnostic labelingand enables comparison of various groupsirrespective of, for example, level of educationor potential diagnoses. Another advantage ofusing the Nordic questionnaire is that theinfluences of possible bias within this ques-tionnaire are similar in other studies using thesame questionnaire, so comparisons betweengroups can easily be made.

Hildebrandt9 concludes that there is suffi-cient correlation between pain experiencedand the results of a standardized clinical exam-ination; Kuorinka et al8 describe this as well.The degree to which a person’s own reportagrees with the opinion of the physiotherapistafter examination varies from 87% to 100%.This means that the answers that 87% to 100%of the participants give on the Nordic ques-tionnaire match the physiotherapist’s findingson examination. These findings support thevalidity of the questionnaire. Kuorinka alsostudied response stability by asking a group of25 nurses the same questions again two weekslater (ie, test-retest), and at least 96% of theanswers were the same.

A factor that can jeopardize the reliability ofresults is nonresponse. For example, a distort-ed view can be given if only people sufferingfrom MSDs complete the questionnaire and

people who do not have any pain do not doso. This is called selective response, and theNordic questionnaire appears to be sensitive toit.10 To minimize the effects of this kind ofselection, every effort was made to ensure thatall the questionnaires that had been distrib-uted were completed and returned. A mini-mum response rate of 80% for questionnaireslike the Nordic is desirable.10

For an additional guarantee of reliabilityand validity, a small pilot study was conductedamong operatieassistenten (N = 10). The ques-tionnaire was complemented with specificquestions on the working situation of oper-atieassistenten. These questions were mainlyintended to explore any topics that the mainquestionnaire might have missed. Experts inthe subject matter were closely involved in thedrafting of the questions. After the question-naire was completed, participants were askedto indicate the time it took them to completethe questionnaire, and short interviews wereused to check that the questions, including theopen-ended ones, were clear. The questionnairewas then adjusted on the basis of the feedback.

SAMPLEThere are 110 hospitals in the Netherlands.

The aim of this study was to include 10% ofthese hospitals in order to generalize to anational level. An appeal was placed in themagazine Operationeel of the LandelijkeVereniging Van Operatieassistenten (LVO[Dutch Organization of Operatieassistenten]).Sixteen operatieassistenten with an interest inresearch and physical stress who were work-ing in 16 hospitals spread throughout theNetherlands responded that they were willingto participate in the research group, so 16 par-ticipating hospitals each had a delegate mem-ber on the research team. The group wasassisted by a project leader, two human move-ment scientists, and an epidemiologist. A valu-able combination of science, research, and professional knowledge on the part of oper-atieassistenten was thus created.

Ten meetings were organized with thisteam. During the meetings, the research proj-ect was prepared, processed, and discussed.The members of this research team were



involved in drafting, distributing, and collect-ing the questionnaires. They also made valu-able contributions to the processing and dis-cussion of the results. This organizationalapproach meant that it was possible to conducta large-sample survey. Personal supervision bymembers of the research team ensured a goodresponse, swift data collection, and objectiveinstructions to the participants during thestudy. Full privacy protection was offered toall participants.

SELECTION OF PARTICIPATING HOSPITALS. The selec-tion of the 16 participating hospitals had beena mix of convenience and chance, so theresearchers discussed the participating hospi-tal sample and compared basic characteristicswith the general national situation. Theyfound the sample to be a good representationof Dutch hospitals. The researchers also wereable to test the data from this study againstdata from a sample of operatieassistenten froma previously performed national survey for theoperatieassistenten labor market in 2001.11 Thedistribution of small, medium, and large hos-pitals in this study is similar to the nationaldistribution.

SELECTION OF OPERATIEASSISTENT SAMPLE. The mem-bers of the research team were instructed tostimulate the response, but at the same time notto compromise the representative nature of thesample. The number of participants could varyfrom one hospital to another, with no minimumand maximum numbers set. In situations whereit was not possible to include the whole ward inthe study, the members of the research teamreceived instructions to avoid unconscious selec-tion effects by selecting participants by thedrawing of lots. Only qualified operatieassisten-ten or operatieassistenten in training (ie, stu-dents) were approached and asked to fill out thequestionnaire.

PRIVACY AND CONFIDENTIALITY. Together with thequestionnaires, the participants received aninformation and instruction form in which thepurpose and procedure of the study wereexplained. Participation was voluntary withoutany consequences for a participant. In theNetherlands, only research studies involvingpatients as participants or studies involvingsome kind of intervention must be reviewed by

a hospital ethics committee. In this case, con-sent forms were not necessary. The completedquestionnaires were collected in closed enve-lopes. This means that it would be nearly im-possible to trace results back to individuals,small groups in hospitals, or separate hospitals,and no insight into the data set would be givento third parties. The questionnaires are kept ina safe and will be destroyed after three years.

DATA ANALYSISThe data from the closed questions were

processed using SPSS PC+ 11.0.12 These aremainly descriptive statistics with means andfrequency data. The chi-square test and t testwere used for questions of difference. Differ-ences were regarded as significant when a P value of ≤ .05 was attained.

RESULTSThe population data for the participating hos-

pitals were compared with a more general refer-ence file11 on the perioperative profession from2001 with labor market data on 80% of all oper-ating departments in the Netherlands (Table 1).Furthermore, from a geographical point of view,the hospitals were well distributed across theNetherlands, and there was a mix of general,specialized, and university hospitals.

RESPONSE. In total, 615 questionnaires weredistributed, of which 463 were returned. Theresponse rate was 75% and varied per hospitalfrom 47% to 100%, for a mean of 29 partici-pants per hospital (standard deviation [SD] =8.2) (Figure 1). In general, there was a goodcorrespondence between the size of the hospi-tal and the number of participants per hospi-tal. The total number of qualified operatie-assistenten participants was 403, and the totalnumber of student operatieassistenten partici-pants was 60.

GENERAL GROUP CHARACTERISTICS. The majority ofthe respondents were women (85.1%). Themean age was 36 years (SD = 10.3), and themean number of years of work experience forthe qualified operatieassistenten was 15.1years (SD = 8.9).

HOURS WORKED. The number of working hoursper week for both operatieassistenten and stu-dent operatieassistenten is given in Table 2.

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Student operatieassistentenhave, on average, more con-tract hours (t = -5,875; df = 465;P < .05) and work less overtime(t = 3,579; df = 396; P < .05) thanqualified operatieassistenten;however, the length of a nor-mal working day is similar forboth groups. In Dutch hospi-tals, personnel typically workeither eight- or nine-hour days,but shorter workday lengthsare also possible.

BREAKDOWN OF TIME SPENT ON

TASKS AND SPECIALIST DUTIES.Broadly speaking, the dutiesof operatieassistenten in theNetherlands comprise threetasks. In the circulator role,they accompany the patient inall phases of the surgical pro-cedure and are the link be-tween the sterile team and theenvironment. In the scrub per-son role, they pass instru-ments as members of the ster-ile team. As first assistants,they assist the surgeon in theprocedure itself. Questions onthe duties to which time isdevoted reveal that scrubbingaccounts for most of theworking time (ie, 39%), fol-lowed by circulating (ie, 35%),first assistant roles (ie, 16%),and miscellaneous tasks (ie,10%). There are minor differ-ences between student oper-atieassistenten and qualifiedoperatieassistenten in regardto the amount of time spenton specific duties.

CHANGES EXPERIENCED IN THE

PHYSICAL DEMANDS OF THE WORK.Participants were asked aboutany changes experienced inthe physical demands of theirwork during the precedingthree months. This is an im-portant question for evaluating

TABLE 1Comparison of the Survey Sample With the

Total Population of Operatieassistenten

Points of Population Sample forcomparison (ie, in the Netherlands)1 this studyTotal number ofoperatieassistenten 4,700 463

Mean age in years 38 36

Ratio of mento women 11:89 15:85

Ratio of qualifiedoperatieassistentento studentoperatieassistenten 82:18 87:13

Mean length ofworking week 28.4 hours 30.6 hours

1. van der Windt W, Steenbeck R, van Eijk W, Talma HF. InspanningBeloond? Onderzoek Naar de Arbeidsmarkt van Operatieassistentenen Anesthesiemedewerkers [A Labour Market Study into theGeneral Professional Context of the Work of Operatieassistentenand Anesthesia Personnel]. Utrecht, the Netherlands: Prismant;2002:25-40.

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

60

45

30

15

0

Number of participants per hospital

FIGURE 1

Hospital

Num

ber

of p

artici

pant

s



prevention programs1 because an increase inphysical demands resulting from an increase inworkload will impede the effect of a preventionprogram, the very aim of which is to reduce thephysical demands placed on staff members. Thetrend toward an increase in physical demandswill first have to be reversed before a decrease instress can occur. When answering this question,respondents also could give a possible reasonfor the change.

Student operatieassistenten were more in-clined to report an increase in physical stressthan qualified operatieassistenten (X2 = 6.96,df = 2, P < .05) (Table 3). Student operatieassis-tenten reported that the reasons are related tothe fact that they are in training and, for exam-ple, have to spend more time passing instru-ments, perform more standing work, and get

used to the physical demands of the job. Thereasons cited by qualified operatieassistentenfor the increased physical stress of the workwere varied. An increase in the number ofworking hours from eight to nine hours perday was the most often cited, along with moregeneral comments such as “it’s getting busier.”

BACK PAIN. Respondents were asked aboutback pain they had experienced in the preced-ing 12 months. The 12-month prevalence forback pain among operatieassistenten was 58%.That is significantly higher than in the generalpopulation in the Netherlands with the sameage and gender characteristics (ie, 40% to43%).13 Table 4 gives the figures in greater de-tail for qualified operatieassistenten and stu-dent operatieassistenten. It appears that theprevalence among student operatieassistenten

TABLE 2Hours Worked

Qualified StudentTotal group operatieassistenten operatieassistenten(N = 463) (n = 403) (n = 60)

Number of contracthours per week 30.5 29.7* 35.6*

Number of overtime 3.3 3.5* 2.0*hours per week

Hours per normalworking day 8.5 8.4 8.5

* significant difference (t test, P < .05)

TABLE 3Physical Stress Experienced in the Preceding 3 Months

Physical stressexperienced in Qualified Studentthe preceding Total group operatieassistenten operatieassistenten3 months (N = 463) (n = 403) (n = 60)Has become greater 19.1% 17.3% 31.7%

Has remained the same 78.9% 80.8%* 66.7%*

Has become lighter 1.7% 1.8%* 1.7%*

* significant difference (Chi-square test, P < .05)



also is high, with more than half of the studentoperatieassistenten reporting back problems(52%). The percentage of those who took sickleave because of back pain, however, is fairlylow. Only 3% to 8% of those with a back painfelt it was necessary to take sick leave.

A second indicator frequently used to out-line the problem is the three-month back painprevalence. This indicator is more sensitive tochanges that may occur during the course of aprevention project. With 46% of the respon-dents having experienced back pain in the pre-vious three months, the rate was comparable toother physically strenuous professions in thehealth care sector. For physically demanding

departments in hospitals and nursing homesand home care in general, percentages between37% and 46% are reported.14 The mean three-month prevalence for back pain in the Dutchhospital population as a whole is 39%.1 Table 5shows again that the problem is just as seriousamong the student operatieassistenten. Almostall staff members (ie, 85% to 90%) continued towork despite having back pain.

OTHER PAIN. Other MSDs such as headaches,neck and shoulder pain, arm and wrist pain,leg and foot pain, and knee pain also can arisebecause of the physical burden placed on theindividual at work. Headaches were includedhere because they may be related to neck and

TABLE 4Back Pain in the Preceding 12 Months andAbsence From Work Because of Back Pain


Experienced backpain in the preceding12 months 267 (58%) 236 (59%) 31 (52%)

Reported an absencefrom work becauseof back pain 36 (8%) 34 (8%) 2 (3%)

TABLE 5Back Pain Prevalence and Absence Among Operatieassistenten

With Back Pain in the Preceding 3 Months


Experienced backpain in the preceding3 months 211 (46%) 184 (46%) 27 (45%)

Continued workingdespite back pain 190 (90% of 211) 167 (90% of 184) 23 (85% of 27)

Reported an absencefrom work becauseof back pain 19 (9% of 211) 18 (10% of 184) 1 (4% of 27)



shoulder pain, although the literature on thissubject is not unanimous.4,15

Table 6 and Figure 2 present the percentagesof participants who reported having had pain.Those who reported pain perceived a clear con-nection between the pain and their work. Thepercentage of sick leave caused by these kinds ofMSDs is relatively low, except for headaches.Headaches are quite prevalent, but far fewer par-ticipants saw them as work-related. Neck andshoulder pain was cited by 53%, more thanthree-quarters of whom reported that the disor-der was work-related. The percentage of partici-pants reporting leg and foot pain (ie, 43%) ishigh compared to the figure for the populationas a whole (ie, 12%).14 Furthermore, the oper-atieassistenten themselves tended to regard theseproblems as being very much work-related (ie,91% of those suffering pain in the legs and feet).The responses to the open-ended questionsclearly reveal that the qualified operatieassisten-ten considered these disorders to be linked toprolonged standing, with swollen feet and some-times varicose veins causing the problems.

In all disorder categories, the student oper-atieassistenten reported pain rates at least ashigh as those of qualified operatieassistenten.Only in the area of pain affecting the feet and

TABLE 6Other Musculoskeletal Disorders During the Preceding 3 Months

Other musculo- Those who Those who Prevalence inskeletal disorders called in think this pain the populationsuffered in the sick because is related to at large (lastlast 3 months: (N = 463) of this their work 3 months)1

Headaches 222 (48%) 36 (16% of 222) 114 (51% of 222)

Neck/shoulder pain 243 (53%) 8 (3% of 243) 188 (77% of 243) 20%

Pain in the arms/hands 63 (14%) 4 (6% of 63) 41 (65% of 63)

Pain in the legs/feet 197 (43%) 13 (7% of 197) 179 (91% of 197) 12%

Pain in the knees 101 (22%) 8 (8% of 101) 63 (62% of 101)

1. Bakker RHC, Knibbe JJ, Friele RD. Rugklachten en andere klachten aan het bewegingsapparaat van het verzor-gend en verplegend personeel van verzorgingshuizen [Back pain and musculoskeletal disorders in Dutch nurses].Tijdschrift voor Sociale Gezondheidszorg: TSG. 1997;75(6):333-338.

Figure 2 • Percentage of participants reporting pain invarious parts of the body during the preceding three months.



legs was a significant difference found. Here therate of student operatieassistenten with painwas 57%, and the rates of qualified operatieas-sistenten with pain was 40% (X2 = 468; df = 1; P< .05).

GENERAL TIREDNESS. Apart from the MSDs,questions inquiring about general fatigue alsowere included. General fatigue can be a signthat an operatieassistent is gradually beingexposed to too much physical strain that doesnot necessarily result in specific pain such asback trouble. The questionnaire gave respon-dents the opportunity to report on a scale of 1to 7 whether they judged their work to be“physically demanding” and how often theyfelt “very tired” or “physically exhausted” as aresult of the work. Approximately half of theparticipants considered the work to be “some-

times” demanding and tiring; one-thirdregarded it as being demanding and tiring“often,” “almost always,” or “always”; andnearly one-third found it “sometimes”exhausting (Figure 3).

PROCEDURES CAUSING DISORDERS OR THOUGHT TO BE

PHYSICALLY DEMANDING. Many people are able todescribe clearly and sometimes in great detailthe moments when they first became aware ofsome form of pain arising while they wereworking. Although work may not be the onlycause, this information does contribute to therisk profile of the work and can be of help inoutlining risk activities and designing preven-tive interventions.

In answer to the question, “Did your prob-lems start during work? If so, please brieflydescribe how that happened,” 51% (ie, 49% of

% reporting work is physically demanding

% reporting they are very tired by work

% reporting they are physically exhausted by work

never hardly seldom sometimes often almost always

ever

always2.4

1.3

14.2

5.3

7.2

19.9

7.7

7.0

25.2

49.2

48.4

32.3

26.9

26.1

5.8

6.8

7.8

2.4

1.8

0.2

2.2

FIGURE 3

50

40

30

20

10

0



the qualified operatieassistenten and 58% ofthe student operatieassistenten) gave an affir-mative answer. The answers to this open-ended question can be categorized into threegroups of causes:• static stress, including

• prolonged standing and remaining in thesame position for long periods;

• having to stand in complex and unfavor-able positions during certain surgicalprocedures;

• sometimes standing for a long time inlead aprons;

• varicose veins or tired, swollen legscaused by prolonged standing; and

• holding equipment (eg, retractors, instru-ments) during certain surgical procedures,

• movement/lifting/pushing/pulling, includ-ing• lifting instrument sets;• transferring patients;• lifting heavy equipment (eg, supports,

parts of the OR bed); and• performing the same tasks repeatedly

and having to do so quickly, and• air flow/air conditioning/draft, including

• draft or downflow while working inawkward positions and

• headache, sometimes caused by the airconditioning or smoke (eg, electrosurgi-cal smoke).

SCORES FOR PHYSICAL STRESS PREVENTION POLICIES. As ageneral indicator, operatieassistenten wereasked to give a score for the physical stress pre-vention policy in their own surgical facility. Inthis study, the mean score was 5.2 on a scale of1 to 10, in which scores lower than 6 are consid-ered unsatisfactory. Not one operating ward inthis study received a mark higher than 5.9.

PRESENCE OF AIDS, APPLIANCES, AND MATERIALS FOR

WORK. When asked whether the ergonomic aids,appliances, and materials for work were suffi-cient, approximately 45% of respondentsanswered in the affirmative. The answers tothe accompanying open-ended question re-vealed that there was a need for more or betterequipment, although respondents had no ideawhat that should be or where to look for it.Ignorance of the possibilities for solutions andperhaps also the still somewhat limited avail-

ability of ergonomic equipment on the marketmay have influenced the answers to this ques-tion, but there seems to be a perceived needfor these kind of solutions.

OTHER SUGGESTED SOLUTIONS. For the question onother suggested solutions, consideration wasgiven not only to the total number of answersbut also to their relevance. The comments inTable 7 are merely a reflection of the survey.The researchers emphasize that the potentialeffects of such solutions should always beevaluated carefully.

Many participants saw solutions in theirown behavior. Mention was often made ofideas such as adopting a good posture duringwork; keeping one’s back straight while work-ing; and changing position regularly, for exam-ple, by shifting weight from leg to leg. Com-ments such as “sitting down more often” wereoccasionally made.

There also was a sizable group, however, thatsought solutions concerning material adaptations:platforms for members of the sterile team to standon, better climate control, lighter OR-bed acces-sories, and lighter instrument trays. Adaptationsto the logistical process also were cited (eg, nothaving to bend over instrument trays).

Others sought solutions in the organizationof the work: discussing and agreeing with thesurgeon on table height, planning and morealternation in the work duties, providing forand training enough people, and organizingthe work area more conveniently. Relation-ships between colleagues also play a part (eg,being able and allowed to give each other tipsand advice more easily).

A large group of participants also looked forsolutions in areas such as information, train-ing, fitness, and exercise, and reference alsowas made to solutions like massages. Consult-ing specialists such as occupational therapistsalso were mentioned.

LIMITATIONSThe sample proved largely to agree with the

population data pertaining to operatieassisten-ten in the Netherlands, comprised 10% of allDutch operatieassistenten, and was geographi-cally well-distributed and contained a mix ofhospital types. On the other hand, the sample



was not made at random, and selection effectscannot be ruled out completely. The responserate (ie, 75%) was high for this type of study butis still slightly below the ideal value of morethan 80%. These factors may limit generalizationto the Dutch population of operatieassistentenand the use of the data as a reference file forfuture comparison. In addition, generalization tothe situation in the United States should bemade with great caution since, besides the limi-tations mentioned, the professional situation ofperioperative nurses is different, and the contentof their work may be different. When comparingthe data, the researchers therefore recommendcomparing the time spent with different tasks,especially the ratio of scrubbing to circulating.

DISCUSSIONThe prevalence of MSDs reported by oper-

atieassistenten is comparable to that of otherprofessions in the health care sector and phys-

ically demanding professionsin industry and construc-tion.16,17 The 58% figure for 12-month back pain prevalenceis high compared to thatfound in other professions.The back pain prevalence forqualified operatieassistentenwas comparable to that ofhealth care staff members inthe home care sector, in nurs-ing homes, and in some hos-pital nursing wards (ie, ortho-pedics, neurology), wherepercentages of 56% to 60% arecited.14,18 The figures also arecomparable to those for otherphysically demanding profes-sions such as steel workers(ie, 59%) and forklift truckdrivers (ie, 65%).16 Many otherprofessions have back painprevalence rates around 27%to 34% (eg, cleaning person-nel, office workers). The per-centages also are well abovethe Dutch mean of 40% to43% for MSDs in the generalpopulation.13

Relatively high pain percentages alsowere noted in questions about three-monthprevalence; 53% of the operatieassistentenreported neck and shoulder pain, 48% re-ported headaches, and 43% noted pain relat-ing to the legs and feet. The three-monthprevalence for back pain was 45%. Neck andshoulder pain in particular were higher thanthe values found elsewhere. Values of 34.9%were reported in the home health care sector,and the mean in the Dutch population is20%.17 Rates for pain affecting the legs and feetalso are relatively high compared to generalpopulation values.

A range of risk factors exist for back prob-lems and neck and shoulder pain, includingstatic positions, poor postures during work, andheavy lifting.19 Certainly static stress is still anoften-underestimated form of physical expo-sure. This could originate from the process ofpassing instruments and providing assistance

TABLE 7Suggested Solutions

InstrumentsLighter sets of instruments and instrument trays

Better retractor systems

Equipment and furnitureHigh sitting/standing support for the scrub person

Better instrument tables

Platforms

Several monitors for viewing procedures

Better ways to operate equipment (eg, monitors, OR lamps)

More convenient storage systems for instrument sets

OR beds with lighter tops that are easier to assemble and disassemble

Wheels for heavy equipment, including arm tables

Patient beds that can be easily approached from the side (ie, areless wide) so that stooping is not required when lifting a patient

Beds that are light and easily maneuverable

Transfer devices for lifting patients horizontally

ClimateNot so cold

Solution for the cold air stream (ie, downflow) from the ceiling



during surgical procedures. Pain in the feet andlegs also may point to static stress. Research inrecent years shows that great attention needs tobe paid to this kind of stress, certainly withrespect to employees in the care sector, in orderto lower the incidence of MSDs and the result-ing degree of absence through illness.1,4

Dynamic stress results from pushing, pull-ing, or lifting activities. The dynamic stressresulting from lifting was assessed in twounpublished pilot studies conducted in 2004,using the National Institute for OccupationalSafety and Health guidelines for manual han-dling.20 Acceptable limits were seldom exceed-ed and, therefore, are not considered to be amajor cause of the disorders.

In the literature, mention also is made ofpsychosocial risk factors that play a part inphysical disorders and resulting absencebecause of illness.21 These include, for example,the pressure of work, lack of support from col-leagues or managers, and lack of control overthe work. Little attention has been paid to psy-chosocial risk factors in this study; however,no suggestions pointing to psychosocial fac-tors were made by the participants in responseto the open-ended questions of the study.Perhaps this is an area for further research.

The relatively low percentage of staff mem-bers calling in sick is seen throughout theentire health care sector.1,14,17 Only 9% of oper-atieassistenten with back problems called insick because of back pain, in contrast to thepercentages seen in other physically demand-ing professions in, for example, the construc-tion industry. A positive explanation could bethat staff members in this sector share a feelingof comradeship and are duty-bound by a senseof responsibility. This trend can lead to extraphysical demands being placed on colleagues,however, or the worsening of an individual’sown disorders. In the data set for this study,there are some hints of longer-term absence.

Traditionally, a high use of sick leave often isthe first solid argument for enacting a cost-effective prevention policy. The operatieassisten-ten suffering from MSDs did report a clear con-nection between MSDs and their work (ie, 51%to 91%), and compared with many other profes-sions, the prevalence of MSDs is high. In spite of

this, use of sick leave for MSDs remains relative-ly low; therefore, there is a danger of the prob-lem being underestimated and not enough atten-tion being paid to preventive measures. This alsois apparent from the scores that operatieassisten-ten gave for their facilities’ prevention policies,with not a single ward in the study receiving asatisfactory mark. For that matter, it would begood to have a prevention policy orientedtoward reducing not only sick leave incidencesand disability claims, but also the prevalence ofMSDs, along with the exposure to physical stres-sors. This suggests less traditional arguments fora prevention policy, such as less tiredness at theend of the working day, a greater chance of staffmembers continuing to work willingly at anolder age, and an improvement of the profes-sion’s image and professionalism.22

Student operatieassistenten reported havingalmost as many MSDs as qualified operatieas-sistenten. In itself, this seems strange sincethese typically are young people who shouldbe able to tolerate a good deal of physicalstress. The student operatieassistenten report-ed having experienced a considerable increasein physical stress after they started working onthe surgical ward. High MSD prevalence instudent operatieassistenten has been reportedpreviously, whereas this prevalence is lower inthe general population.17 This again points tooccupational risk factors.

The use of standardized questions, theinvolvement of experts in the study, and con-ducting the small pilot study provided a suffi-cient guarantee of the study’s reliability andvalidity. By using standardized questions, thebias in various groups is considered equal andas a result, good comparisons are possible.

In the section containing open-endedresponses, questions were raised about thecauses and preventive measures that oper-atieassistenten themselves believed were rele-vant. This led to a wide range of problems andcauses being cited and a collection of ideas andtips. Prolonged standing and the necessity ofsometimes having to stand in uncomfortablepositions was given prominent mention. Lift-ing situations and climate also were reportedas aggravating factors.

Intrinsically, no value judgment was attached



FIGURE 4Compact Questionnaire for the Operating Department

1. Have there been any changes during the last three months in the physical demands placed on you byyour work?

No, physical demands have remained the same.Yes, the work has become more physically demanding becauseYes, the work has become less physically demanding because

2.

hardly some- almost3. never ever seldom times often always alwaysI am physically very tired after my work. 1 2 3 4 5 6 7I feel physically exhausted by my work. 1 2 3 4 5 6 7I find my work physically demanding. 1 2 3 4 5 6 7

4. What do you feel are the most obvious reasons for high physical demands during your work?

Materials

Work methods

Cooperation

Working conditions

Other

5. What are your suggestions for potential preventive solutions to this problem?

Materials

Work methods

Cooperation

Working conditions

Other

6. What score would you give your ward for the quality of its prevention policy? Please circle.(No policy = x)

x 0 1 2 3 4 5 6 7 8 9 10

7. How old are you? ________

8. Are you an operatieassistent or a student operatieassistent?

During the last 3 months, Have you taken sick Do you think the painhave you suffered from: leave because of this? is related to your work?Headaches Yes/No Yes/No Yes/NoNeck/shoulder pain Yes/No Yes/No Yes/NoPain affecting the arms/hands Yes/No Yes/No Yes/NoBack pain Yes/No Yes/No Yes/NoPain affecting the legs/feet Yes/No Yes/No Yes/NoPain affecting the knees Yes/No Yes/No Yes/No



to the answers to the open-ended questions inthis study, although the answers are presentedin the results section. This was consideredimportant because in this way, it is possible togain a good overview of the causes of theproblems and possible solutions for themfrom the perspective of those most directlyinvolved. Attaching importance to this infor-mation results in a significantly better chanceof a good—and in particular wide-ranging—prevention policy than when only the moreobjective data are taken into account. It isimportant to make the observation thatthought is being given to physical stress andthat there also is an intention to find solutions.

RECOMMENDATIONSListening to the signals coming from the

work floor and participation of employees inthe design of the prevention program is essen-tial for a successful prevention policy.1,17 Asmentioned, remarkably few psychosocial fac-tors are highlighted, although it is generallyknown and also is cited in the literature thatthe psychosocial climate can affect physicaldisorders.21 More attention could perhaps havebeen given to this aspect of this study, and it isrecommended that this be the subject of fur-ther research.

The questionnaire used in this study could,in a more compact form, constitute part of aquick scan in every surgical ward. The ques-tionnaire (Figure 4) can easily be analyzedmanually or in a spreadsheet. The series ofquestions on three-month prevalence, sickleave, and the work-related nature of disordersgenerally are ideally suited for the assessmentof the effect of preventive measures.

For an effective and efficient MSD preven-tion policy, it is worth looking for the mostaggravating components of the problem. Awell-known rule is Pareto’s principle, alsoknown as the 20-80 rule: often 20% of the caus-es are responsible for 80% of the effects.23 It isessential to avoid taking expensive measuresthat scarcely have any effect while simple,effective measures are ignored. This can beavoided by objectively checking the results ofall preventive measures. A prevention policyshould lead to lower pain percentages, and the

previously mentioned assessment methodcould play a part here.

Based on the results of this study, the re-searchers recommend that more attention bepaid to the physical working conditions ofperioperative personnel. The results point tothe preventive relevance of including not onlyoperatieassistenten already experiencing prob-lems, but also student operatieassistenten inpreventive interventions. To make changesand promote a supportive environment forchange and a positive preventive culture, man-agement support is essential. To study theeffectiveness and cost-effectiveness of preven-tive interventions, longitudinal studies, prefer-ably with a randomized control group, arestrongly recommended.

Editor’s note: This study was financed by theSectoral Funds for Care and Welfare, whichimplemented the Hospital Working Covenant con-cluded in 2001, and the Dutch Organization ofOperatieassistenten (LVO). The translation of thisarticle was sponsored by Mölnlycke Health Care,Benelux, the Netherlands.

REFERENCES1. Knibbe JJ, Hooghiemstra F, Knibbe NE.Arboconvenant Ziekenhuizen: Stand der Techniek[Hospital Working Conditions: Present Situation andRecommendations for Change]. Doetinchem, theNetherlands: Elsevier Bedrijfsinformatie; 2001:2-5.2. Zorgnota 2001 [Government Care Policy]. Den Haag,the Netherlands: Tweede Kamer, Vergaderjaar;2000-2001:178-191.3. Kant IJ, de Jong LC, van Rijssen-Moll M, BormPJ. A survey of static and dynamic work postures ofoperating room staff. Int Arch Occup Environ Health.1992;63(6):423-428.4. Meijsen P, Knibbe H, Knibbe N. De FysiekeBelasting van de Instrumenterende Operatieassistent[The Physical Load of Operatieassistenten]. Utrecht, theNetherlands: van de Sectorfondsen Zorg en Welzijn;2003:1-25.5. Garb JR, Dockery CA. Reducing employee backinjuries in the perioperative setting. AORN J. 1995;61(6):1046-1052.6. Owen BD. Preventing injuries using an ergonom-ic approach. AORN J. 2000; 72(6):1031-1036.7. Polit DF, Hungler BP. Nursing Research: Principlesand Methods. 6th ed. Philadelphia, PA: Lippincott;1999:331-362.8. Kuorinka I, Jonsson B, Kilbom A, et al. Standard-ised Nordic questionnaires for the analysis of muscu-loskeletal symptoms. Appl Ergon. 1987;18(3):233-237.



9. Hildebrandt VH. Prevention of Work RelatedMusculoskeletal Disorders: Setting Priorities Using theStandardized Dutch Musculoskeletal Questionnaire.Delft, the Netherlands: TNO Arbeid; 2001:45-53.10. Dickinson CE, Campion K, Foster AF, NewmanSJ, O’Rourke AM, Thomas PG. Questionnaire devel-opment: an examination of the Nordic Musculo-skeletal questionnaire. Appl Ergon. 1992;23(3):197-201.11. van der Windt W, Steenbeck R, van Eijk W,Talma HF. Inspanning Beloond? Onderzoek Naar deArbeidsmarkt van Operatieassistenten en Anesthesie-medewerkers [A Labour Market Study into the GeneralProfessional Context of the Work of Operatieassistentenand Anesthesia Personnel]. Utrecht, the Netherlands:Prismant; 2002:25-40.12. SPSS—Statistical Package for the Social Sciences.Version PC+ 11.0. Chicago, Ill: SPSS, Inc; 2003.13. Picavet HSJ, van Gils HWV, Schouten JSAG.Klachten van Het Bewegingsapparaat in de NederlandseBevolking, RIVM Rapport 266807 002 [NationalStatistics on Musculoskeletal Disorders in the DutchPopulation]. Bilthoven, the Netherlands: RIVM;2000:18-44.14. Bakker RHC, Knibbe JJ, Friele RD. Rugklachtenen andere klachten aan het bewegingsapparaat vanhet verzorgend en verplegend personeel van ver-zorgingshuizen [Back pain and musculoskeletal dis-orders in Dutch nurses]. Tijdschrift voor SocialeGezondheidszorg: TSG. 1997;75(6):333-338.15. Haldeman S, Dagenais S. Cervicogenic head-aches: a critical review. Spine J. 2002;1(1):31-46.16. Burdorf A. Assessment of Postural Load on theBack in Occupational Epidemiology. Rotterdam, theNetherlands: Erasmus Universiteit; 1992:111,141.17. Knibbe JJ, Friele RD. Prevalence of back painand characteristics of the physical workload of com-munity nurses. Ergonomics. 1996;39(2):186-198.18. Moens GF, Dohogne T, Jacques P, van Helshoecht

P. Back pain and its correlates among workers infamily care. Occup Med (Lond). 1993;43(2):78-84.19. Chaffin DB, Andersson GBJ, Martin BJ. Occu-pational Biomechanics. 3rd ed. New York, NY: JohnWiley & Sons, Inc; 1999:28-59.20. Waters TR, Putz-Anderson V, Garg A. Applica-tions Manual for the Revised NIOSH Lifting Equation[NIOSH publication no. 94-110]. Cincinnati, OH: USDepartment of Health and Human Services, Centersfor Disease Control and Prevention, National Insti-tute for Occupational Safety and Health, Division ofBiomedical and Behavioral Science; 1994.21. Bongers P, Ariens G, van den Heuvel S, MiedemaM, Douwes M. Risicofactoren voor Nekklachten. [RiskFactors for Neck Pain]. Den Haag, the Netherlands:Elsevier Bedrijfsinformatie; 2000:42-43.22. Knibbe JJ, Knibbe NE, Geuze L. WerkpakketBeter! [Practical Tools for Ergonomic PreventiveInterventions in Hospitals]. Utrecht, the Netherlands:Sectorfondsen Zorg en Welzijn; 2003:9-12.23. Benjamin M, Shaw JG. Harnessing the power ofthe Pareto principle. 1993. Shaw Resources. http://www.shawresources.com/artpareto.html. AccessedFebruary 5, 2007.

Paul Meijsen, BEd, MA, is an operatie-assistent at Catharina Hospital, Eindhoven,the Netherlands, and a lecturer at the FontysUniversity of Applied Sciences, School ofNursing, Eindhoven, the Netherlands.

Hanneke J. J. Knibbe, MSc, RPt, is a regis-tered physiotherapist and human move-ment scientist at Locomotion Health Adviceand Research, Bennekom, the Netherlands.

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