Original Research Article INQUIRY: The Journal of Health Care Organization, Provision, and Financing Occupational Diseases and Perceived Health Volume 58: 1–8 © The Author(s) 2021 in Operating Room Nurses: A Multicenter Article reuse guidelines: sagepub.com/journals-permissions DOI: 10.1177/00469580211060774 Cross-Sectional Observational Study journals.sagepub.com/home/inq Marı́a del Mar Martı́-Ejarque, RN, MSc, MEd1 , Gemma Guiu Lázaro, RN2, Roser Coutado Juncal, RN1, Salvador Pérez Paredes, RN3, and Cecilia Dı́ez-Garcı́a, RN, MSc2  Abstract Background: The surgical environment has multiple factors that could affect nurses’ health. The aim was to determine the effects of the working environment of operating room nurses on their health compared to hospitalization nurses. Methods: A sample of operating room nurses and hospitalization nurses were included in the study and participated by filling in a self-report survey containing sociodemographic data items, the validated Nordic and SF12 scales and a list of medical conditions. Results: Three hundred and thirty-one nurses participated in the study. Statistically significant results had obtained for di- agnoses of musculoskeletal disorders and contact dermatitis among the operating room nurses. Conclusion/Application to Practice: Continuous training in ergonomics is essential. Moreover, surgical protocols for pre- venting infection should be revised, optimizing the chlorhexidine content of soaps to reduce the risk of lesions among the surgical staff. Keywords cross-sectional studies, demographic and health surveys, nursing research, occupational diseases, perioperative nursing What do we already know about this topic? There is no previous research comparing the health of surgical nurses to inpatient nurses by assessing risks in the workplace. How does your research contribute to the field? Surgical nurses and hospital ward nurses face various health risks in their workplace due to exposure to biological agents, chemical agents (disinfectants and inhalation anaesthetic agents), radiation and physical burden due to patients or in- struments’ handling surgical. In developed countries, there is specific legislation that regulates safety in the workplace. However, such legislation is not enough to prevent risks and secondary diseases suffered by professionals. What are your research’s implications towards theory, practice, or policy? Knowledge about occupational risks and improvement actions allow minimizing the harm suffered by nurses. 1 Hospital Universitari Sagrat Cor, Grupo QuirónSalud, Barcelona, Spain Corresponding Author: 2 Hospital de la Santa Creu i Sant Pau, Barcelona, Spain Cecilia Dı́ez-Garcı́a, Hospital de la Santa Creu i Sant Pau, Sant Antoni Maria 3 Hospital Universitari San Juan de Alicante, Sant Joan d’Alacant, Spain Claret 167, Barcelona 08025, Spain. Email: cdiez@santpau.cat Creative Commons Non Commercial CC BY-NC: This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 License (https://creativecommons.org/licenses/by-nc/4.0/) which permits non-commercial use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage). 2 INQUIRY Background The authors of this work intended to analyse different reasons for a high percentage of work absenteeism. The The work environment in which nurses carry out their daily suspicion that these absences were related to the hostile en- work face situations and substances that can harm health. It is vironment nurses were subjected to would not be surprising. conditioned by the continuity of shifts for 24 hours, the occupational risks present in the different healthcare areas and the predominant female gender characteristic of this Methods profession. In working life, acute and chronic pathologies appear Aims among the nursing community and are related to working The main objective of this study was to determine the effects conditions and their environment. of the working environment of operating room nurses on their Many nurses wonder if working in this profession is health compared to hospitalization nurses. The secondary harmful to their health. objectives were (1) to know the existing pathologies among The health and working conditions of the nursing staff nurses depending on their work area and seniority in the (instability, job insecurity, excessive workload and reduced workplace; (2) to establish how nurses perceive musculo- salaries) and the low participation in decision-making that skeletal disorders and (3) to compare nurses’ perceived health affect workplaces constitute important psychosocial risk with that of the general population. factors. This situation has been progressively deteriorating throughout the world. It has been reflected in the decrease in university demand and the desertion of the profession. Study Design The Health and Safety Manual of the National Institute of It was a multicenter cross-sectional observational study carried Healthcare Management (Instituto Nacional de Gestión Sanitaria) out in four Spanish hospitals (one hospital with more than 500 classifies risks associated with the workplace as follows1: Ex- beds, one hospital with between 200 and 500 beds, one hospital posure to biological agents: Pyrolysis of tissues produces ul- with less than 200 beds and one hospital with less than 100 beds). trafine particles, volatile chemicals and biological compounds some of which are teratogenic or carcinogenic. Surgical plume irritates the respiratory tract and the eyes.2,3 Exposure to chemical Study Population pollutants: Disinfectants4 and inhalational anaesthetic agents: The study population were composed of 331 operating room Several studies have shown that chronic exposure to these nurses and ward nurses working from four Spanish hospitals substances can cause hepatic and kidney alterations in surgical between December 2018 and February 2019. All participants staff.5 Contact dermatitis and latex allergy: Surgery staff are were volunteers. They had recruited in the initial introductory healthcare workers with the highest prevalence of latex allergy.6,7 study meeting between January 2019 and September 2020. Women present more symptomatology than men, as with other The inclusion criteria were (1) operating room nurses who atopic disorders.8-10 Repeated use of gloves to perform tasks worked as scrub nurses, circulating nurses or anaesthesia together with frequent use of soaps and liquid disinfectants and nurses and (2) hospitalization nurses. insufficient drying of the hands favours the appearance of The exclusion criteria were (1) careers without the pro- symptoms compatible with contact dermatitis.11 Radiation ex- fessional status of nursing staff; (2) working for less than one posure: Studies have shown increased papillary thyroid cancer year and (3) scrub nurses working sporadically in the centre. incidence due to medical radiation.12 Load bearing caused by handling objects/patients: Risk factors for suffering back prob- lems include standing still for long periods, lifting heavy objects Data Collection and patient mobilization.13,14 Work-related stress: Prolonged All nurses who met the inclusion criteria were consecutively stress can harm health and can trigger diseases.15 Studies warned in the study as they answered the questionnaire between that burnout could lead to serious health problems and reported December 2018 and February 2019. Nurses were grouped increases among healthcare staff.16 Some authors consider that into two groups according to the professional group who around 25% of nurses suffer from burnout.17 This syndrome can worked their role: Surgical nurses or hospitalization nurses. trigger the onset of severe depression, alcohol and abuse of mood- The number of cases included in the present study was altering substances, hypertension and chronic disorders.16 314, distributed evenly between the two participating groups According to Peipins et al.,17 suicide was among the five (157 in each group).To justify this number, we started from most common causes of death among nurses, and that they variability of 30% (CV) from the publication of Vilagut et al. also had higher rates of suicide than the general population. (2008). The difference to be detected between both groups Long rotating work shifts in addition to excess workloads was set at 5 points, which would be an approximate effect of cause stress and contribute to low job satisfaction and ex- 10%; losses were not more significant than 10%. Finally, we haustion, leading to other health problems such as obesity, estimated the 5% for the alpha error probability and a beta cardiovascular diseases and type II diabetes.18 error of 20% (minimum power of 80). Martı́-Ejarque et al. 3 Study Variables Student’s t-test for nonnormally distributed and independent data t-test for normally distributed quantitative variables. In The research team members delivered the surveys by hand after all cases, the significance level was 5% (α = .05). Data presenting the study to the participants and collecting the in- analysis was performed using IBM SPSS (version 24). formed consent document in their respective hospitals. Those who agreed to participate signed a consent document, and once the questionnaires had been answered, they were returned to the Ethical Considerations researchers by hand. In the four hospitals, the entire staff of The research project had the approval of the clinical research permanent surgical nurses participated in the study voluntarily. ethics committees of the different hospitals. However, the group of hospitalization nurses was assumed The study variables were registered in the Zenedo.org consecutively until the calculated n was achieved. The survey available from https://zenodo.org/record/4501280in Febru- consisted of questions with multiple-choice answers to deter- ary 2021. mine the perceived health and know the nurses’ pathologies. Investigators complied with fair clinical practice laws and The primary outcome variables of the study determined the ethical principles for research in human beings described the effects of the working environment of operating room in the Helsinki Declaration version updated in the 64th nurses on their health compared to ward nurses, which was General Assembly, Fortaleza, Brazil, October 2013. Confi- determined with the health perception of each of them. dentiality and privacy of personal data had been guaranteed The research team provided all nurses with an anonymous by ensuring compliance with European data protection laws, questionnaire to be completed in writing. It consisted of 28 namely, with Regulation (EU) 216/679 of the European closed questions with multiple-choice answers to assess Parliament and Committee of 27/04/2016 (RGPD-Spanish perceived health and musculoskeletal symptoms and describe Agency for Data Protection). their diagnosed pathologies. Each study participant was handed an informative sheet The questionnaire’s questions on perceived health were about the study and had asked to sign the informed consent. constructed from the Modified Scale SF12.20 This Scale is a Participation was voluntary and anonymous, and the par- reduced version of the SF36 Scale, used throughout the world ticipant could withdraw from the study at any time. since the 1990s to measure the health status, which in the All questionnaires and informed consent documents had present study was called perceived health, of the general stored in the archives of one of the hospitals, where they will population.21 Question 2 of the SF36 was added to the Scale of remain for 25 years after the publication of this article, after this study due to the interest it represented. One point was which they will destroy. awarded for an affirmative answer in dichotomous answers and 0 points for a negative answer. In multiple-choice questions, the score was awarded from 0–very bad to 4–very good or Results from 0–not pain to 5–much pain or 0–always to 5–never. A total of 331 nurses participated in the study, 165 were In the questionnaire, questions on musculoskeletal symp- operating room nurses and 166 worked on a hospitalization toms presented with the Nordic Scale22 are widely used in unit. Most of the participants were women (87.9%) aged occupational health to detect musculoskeletal symptoms easily. between 22 and 63 years (mean = 42, SE ± 11.59) with around It is a standardized questionnaire for the detection and analysis 17.81 years of work experience (SE ± 11.58). of musculoskeletal symptoms, applicable in the context of The characteristics of the participants included in the study ergonomic or occupational health studies to detect the existence are shown in Table 1 and Table 2. of initial symptoms, which have not yet constituted disease or The study group in Table 3 shows the analysis of perceived have not yet led to consulting the doctor. One point was health. Surgical nurses perceive having a perfect health status awarded for an affirmative answer in questions with dichoto- 53.8 (n = 43) vs 46.3 (n = 37) of hospitalization nurses. Also, mous answers and 2 points for a negative answer. The rest of the surgical nurses perceived good health status 59.3 (n = 51) vs questions quantified the time of the duration of the episode. 40.7 (n = 35) (P = .395). Spearman’s correlation coefficient revealed a statistically significant relationship between the nurses’ perceived health, age and years of nursing experience, Data Analysis with the older nurses with more years of nursing experience After assessing normality, normally distributed data were presented poor perceived health (P = .01). described as mean and standard deviation (SD), nonnormally Figures 1 and 2 show differences between nurses and the distributed data were described as the median and general population concerning perceived health. interquartile range (IQR) and frequency data were reported as The scores on the Nordic questionnaire reflect the areas absolute frequency and percentage. For the study of the re- where the participants experienced more pain or discomfort. lationship between variables, statistical tests were used ac- It is shown in Table 4 that the four areas with the highest cording to the nature of the variables: Chi-square or Fisher’s incidence were the neck and shoulder in both groups. exact test for categorical variables, Mann–Whitney U test or However, in the dorsal–lumbar lower back area, the highest 4 INQUIRY Table 1. Distribution of the participants among the hospitals and working units. Surgical Nurses Hospitalization Nurse Total Hospital n (%) n (%) n (%) P Value > 500 beds 94 (57.0) 106 (63.9) 200 (60.4) .406 200–500 beds 38 (23.0) 27 (16.3) 65 (19.6) <200 beds 26 (15.8) 24 (14.5) 50 (15.1) <100 beds 7 (4.2) 9 (5.4) 16 (4.8) Table 2. Characteristics of the participants recruited into the study, by the group. Surgical Nurses Hospitalization Nurses P Value n (%), Mean (SD) n (%), Mean (SD) Gender Male 12 (7.27) 28 (16.86) .007 Female 153 (92.72) 138 (83.13) Age 43.48 ± 11.18 42.00 ± 11.98 .245 Work experience 17.44 ± 10.87 18.18 ± 12.25 .477 Table 3. Perceived health by the study group. Surgical Ward Nurses Nurses n (%) n (%) P Value Question 7: Perceived health by nurse .395 Excellent 8 (42.1) 11 (57.9) Perfect 43 (53.8) 37 (46.3) Good 35 (40,7) 51 (59.3) Average 8 (53.3) 7 (46.7) Bad 0 (.0) 1 (100) Question 8: Perceived health today compared to a year ago .328 Better 2 (28.6) 5 (71.4) Something better 5 (38.5) 8 (61.5) More or less the same 64 (47.4) 71 (52,6) Something worse 22 (48.9) 23 (51.1) Much worse 0 (.0) 1 (100.0) Question 9: Limitation of activities with current health .852 Little effort (vacuuming and bowling) Yes, limits me a lot 3 (37.5) 5 (62.5) Yes, limits me a little 23 (45.1) 28 (54.9) Does not limit me 139 (51.1) 133 (48.9) Moderate effort (go up several floors) Yes, limits me a lot 5 (55.6) 4 (44.4) Yes, limits me a little 39 (50) 39 (50) Does not limit me 121 (49.6) 123 (50,4) Question 10: Problems at work or daily activities for your physical health in the last 4 weeks Did less than what I wanted to do 43 (50.6) 42 (49.4) .823 Had to stop doing some activities 120 (49.2) 124 (50.8) Question 11: Problems at work or daily activities for your psychological or emotional health in the last .428 4 weeks Did less than what I wanted to do 28 (45.2) 34 (54.8) Did not do his work or activities 136 (50.7) 132 (49.3) Martı́-Ejarque et al. 5 scores were recorded in the surgical nurse’s group, 73.4% (n = 69) vs 66.4 (n = 71). The same happens with the knee. The surgical nurses obtained higher scores, 26.6 (n = 25) vs 19.6 (n = 21) for hospitalization nurses. On the other hand, hospitalization nurses presented higher scores in hip–leg, 27.1 (n = 29) vs 23.4 (n = 22) for surgical nurses. Table 5 shows the diagnosed pathologies. A higher per- centage of surgical nurses than in the hospitalization nurses presented dermatitis (P = .026). Also, it is remarkable that 42.6% of surgical nurses working in this area had muscu- loskeletal disorders vs 25.2% of hospitalization nurses, this Figure 1. Perceived physical health by nurses compared to general population. difference being statistically significant (P = .009). However, in the group of hospitalization nurses, the percentage of high blood pressure was higher (P = .031). Discussion This study looks at the possible presence of the pathologies described in the literature and the participants’ perceived health. Also, it investigated a possible link between any of these medical conditions and the different surgical areas. In the introductory meeting of the study, it became evident that the list of these pathologies is pervasive, and we decided to focus on the most important ones or those for which the conditions of the operating room nurse presented the most predisposing factors. The main objective of the present study was to determine the effects of the working environment of operating room Figure 2. Perceived mental health by nurses compared to general nurses on their health compared to hospitalization nurses. population. According to our results, we can only affirm that the operating Table 4. Nordic questionnaire by group the study. Surgical Nurses Ward Nurses n (%) n (%) P Value Question 15: Have you had discomfort in... Neck Yes 61 (64.9) Yes 67 (62.6) .738 No 33 (35.7) No 40 (37.4) Shoulder Yes 45 (47.9) Yes 48 (44.9) .669 No 49 (52.1) No 59 (55.1) Dorsal or lumbar lower back Yes 69 (73.4) Yes 71 (66.4) .278 No 25 (26.6) No 36 (33.6) Elbow or forearm Yes 11 (11.7) Yes 9 (8.4) .437 No 83 (88.3) No 98 (91.6) Wrist or hand Yes 27 (28.7) Yes 24 (22.4) .306 No 67 (71.3) No 83 (77.6) Hip or leg Yes 22 (23.4) Yes 29 (27.1) .548 No 72 (76.6) No 78 (72.9) Knee Yes 25 (26.6) Yes 21 (19.6) .241 No 69 (73.4) No 86 (80.4) Ankle or foot Yes 14 (14.9) Yes 20 (18.7) .474 No 80 (85.1) No 87 (81.3) 6 INQUIRY Table 5. Diagnosed pathologies by the study group. Stress Surgical Nurses Ward Nurses Individual working conditions make operating room nurses vulnerable to permanent work-related stress.16 Work over- n (%) n (%) P Value load, a lack of staff or resources, the constant need to learn Asthma 19 (11.5) 13 (7.8) .172 how to use the latest technology and the urgency of the Dermatitis 35 (21.21) 21 (12.66) .026 situations, which require staff to act urgently and responsibly, Allergy latex 3 (1.80) 5 (3.03) .365 can trigger burnout syndrome. In our study, 19.1% of the Hepatitis 3 (1.80) 1 (.60) .309 operating room nurses and 14.0 ward nurses suffered from Thyroidism 12 (7.22) 7 (4.24) .248 stress. The overall results reflect the situation that the pro- Kidney disorders 3 (1.80) 4 (9.69) .503 fession is facing currently. All hospital departments are ex- Abortion 15 (9.03) 10 (6.60) .199 periencing a significant generational change, making it Cataract 3 (1.80) 1 (.60) .309 impossible to replace all the nursing staff. The nursing staff Carpal tunnel syndrome 2 (1.2) 8 (4.84) .104 are aggravated by a lack of stability and security, leading to Musculoskeletal diseases 40 (42.6) 27 (25.2) .009 excessive workloads and few incentives to seek professional Work stress 18 (19.1) 15 (14.0) .327 promotion. It decreases in salaries causing feelings of frus- High blood pressure 3 (3.2) 12 (11.2) .031 tration, ill-feeling and demotivation among the nursing staff. Diabetes mellitus 2 (2.1) 4 (3.7) .503 These well-known aspects directly or indirectly affect nurses’ Depression 5 (5.3) 9 (8.4) .390 perceived mental health and negatively affect their lifestyle. Tumour 3 (2.8) 0 (.0) .102 In 2012, Schmidt et al. studied the perceived health of a general population sample using the same SF12 Scale.24 Therefore, with the results of both studies, it has been pos- room work environment has adverse effects on the health of sible to compare nurses’ perceived health as a professional surgical nurses compared to hospitalization nurses when we group with that of the general population. The scores obtained refer to musculoskeletal diseases and dermatitis. Compared show that nurses presented slightly lower scores for perceived to the rest of the pathologies studied, no statistically sig- mental health than the general population. When observing nificant differences were observed between both pop- the results about groups of the different age ranges, physical ulations. It is appreciated without sufficient statistically health perception can be lower or higher depending on the significant evidence that there are more cases of the pop- participants’ age but not statistically significant. Only the ulation with thyroid problems in the surgical nurses, with groups under 25 years old and nurses over 55 had a worse 7.22% (n = 12) of cases, slightly higher than the cases perceived physical health than the general population. Mental reported by hospitalization nurses that it represents 4.24% health is scored with the worst values for nurses when we (n = 7) of the total (P = .248). In the same way, we observed compare it with the general population. a slight increase in fertility problems in the surgical pop- ulation, from the surgical nurses reported infertility in 9.03% (n = 15) compared to 6.60% (n = 10) of affected Contact Dermatitis people in the hospitalization area (P = .199). Interestingly, in our study, contact dermatitis was signifi- cantly more prevalent in one of the hospitals, detected in 20.9% of the nurse participants. The reason for this is known Musculoskeletal Disorders as the concentration of chlorhexidine antiseptic solution in It is highly prevalent internationally among perioperative this hospital was increased from .4 to .8% to prevent post- nurses and is the leading cause of absenteeism and requests operative infection. Moreover, a higher prevalence of skin to change work posts.13 Although a part of the sample from conditions in healthcare professionals has linked to higher surgical nurses referred some pathology, only 10.9% of concentrations of this product. We notified our results to the them requested a change of surgical specialty. Approxi- hospital’s Health and Safety Department to highlight its mately one in three cases of absence among operating room importance for staff health and safety. nurses are linked to musculoskeletal disease.14 The nurse/patient ratio in Spain is far below the European Several studies on MSD among perioperative nurses show average. Only five nurses are employed to care for 1000 similar results to this study, regardless of their location patients, while the European average is almost nine. This worldwide.23 They reported results similar to our study that situation directly affects the nursing staff’s work and health, 58% of operating room nurses suffered from back pain in the who experience excess workloads in the hospitalization and previous 12 months and 85–90% of these continued working operating rooms. results. 11.2% only requested to transfer nurses, who had Current legislation should incorporate measures to im- consequently transferred to another healthcare unit or service, prove the nurse/patient ratio. Many healthcare professionals similar to our results, 10.9% of the surgical nurses. do not take enough care of their health and do not even follow Martı́-Ejarque et al. 7 the advice they give to their patients. Healthcare professions, Acknowledgements especially nursing, require a strong social commitment and We want to thank all the nurses who have collaborated altruistically work under tremendous pressure. This situation can nega- in our study. We would also like to thank Dr Ignasi Gich and Dr tively affect the workers’ mood and emotional balance, es- Margarita Aguas for collaborating in the initial statistical analysis of sential to working healthily and providing patients with the results and their support. We are grateful to the student Mireia adequate care. Estrada Ros, who participated in the data collection in one of the The nursing profession’s physical and emotional efforts study hospitals. are very similar in all healthcare departments of the hospital, which is reflected by our results. Declaration of Conflicting Interests Occupational risks are limited as they are carefully controlled by the Health and Safety Departments of the hospitals studied. The author(s) declared no potential conflicts of interest with respect Training is one of the most critical areas to prevent oc- to the research, authorship, and/or publication of this article. cupational hazards and professional diseases. Rather than targeting a specific goal, this should regard to explore and Funding understand in greater depth the situations that arise in this The author(s) received no financial support for the research, au- setting, particularly the work environment, the working thorship, and/or publication of this article. conditions and the resources available. It is essential to provide continuous training in ergonomics and special ap- Code Ethics Committee paratus to prevent lumbar and dorsal injuries in all hospital On the 7/11/2018 with 2018/54-INF-HUSC code ethics committee, departments. Moreover, prevention protocols of surgical the study was approved with idcsalud at Catalunya. infection should be revised to optimize the proportions of chlorhexidine in soaps to help prevent skin lesions among ORCID iDs operating room staff. In-depth knowledge of the occupational hazards and the Marı́a del Mar Martı́-Ejarque  https://orcid.org/0000-0002-0363- actions required to address them will minimize the harm 3327 suffered by operating room nurses and ward nurses alike. Cecilia Dı́ez-Garcı́a  https://orcid.org/0000-0003-3957-2148 The results obtained with a sample of this size help es- tablish initial associations, which must explore in greater References depth in further studies. 1. Domı́nguez Fernández JM, Ortega Martı́n G, Martı́nez Bagur ML, Garcı́a Álvarez J, De la Vega Durán L, Fernández Delgado MT. Manual de Prevención de Riesgos Laborales Del Instituto Limitations of the Study Nacional de Gestión Sanitaria, Vol 1. Madrid: Instituto Na- The sample of operating room nurses was approximately 99% cional GS; 2011. http://www.ingesa.msssi.gob.es/estadEstudios/ of the permanent staff in the hospitals studied. 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