Progress in Protection of Nurses Working in Operating Room against Occupational Hazards
Lin Xueqin, Hong Siyou, Cai Lixia
Yangjiang People’s Hospital, Yangjiang, Guangdong 529500, China
Occupational hazards have been attracting attention from medical workers in recent years. As a special space for treatment, the operating room is surrounded by biological, chemical, physical, socio-psychological and other hazards, threatening the physiological and psychological health of medical workers. Hence, the protection against occupational hazards is very important to the health of nurses who are working in operating room and the quality of nursing.
Keywords: Operating room; prevention; occupational hazards
Along with the rapid development of medicine and the improvement of medical technology in recent years, the operating room is an important place for rescuing people in a hospital. Nurses working in operating room have frequent contact with body fluids of patients, and are often exposed to chemicals, harmful gases and radioactive instruments. In addition to fast tempo, high pressure and irregular working hours, nurses become easily infected during their work.
1. Common Hazards
1.1 Socio-psychological hazards:
The nurses working in the operating room undertake technical assignments and cumbersome manual labour. In their work, there are lots of factors causing overload. On one hand, nurses bear high workloads, too many requirements in their work and they suffer unreasonable scheduling and shifting which disrupt their biological clock. On the other hand, nurses must face the lack of understanding pertaining to patients and their families, disapproval from surgeons, violence tendency and sexual harassment at workplace. As patients suffer from pains, discomfort, tension, pressure and anger, receiving no privacy protection and waiting for too long, etc., they may become depressed, resulting in physical and oral abuse [1-2]. Secondly, the role of the nurse often conflicts with regular roles in daily life, leading to stress at work. If the situation lasts for a long time and accumulates beyond the capability of self-regulation, it may cause anxiety, depression, tension and other emotions or lead to other pathological symptoms .
1.2 Biological hazards:
These include bacteria and viruses, etc. As nurses are often in contact with the bloods, secretions and excretions of patients, they are more often infected by these contaminants. Especially when a nurse has a damaged skin on hand, the mucous membranes of skin will be contaminated during cooperation during operation, which very easily causes the infection of blood-transmitted diseases and the implantation and growth of tumor. When a person is exposed to Hepatitis B virus (HBV), Hepatitis C virus (HCV) and HIV by one-time punching or in any other skin-related way, the average infection rate is 6%~30%, 3%~10% and 0.2%~0.5% respectively . In addition, other body fluids that nurses are exposed to are also important routes of inflection, such as synovial fluid, vaginal fluid, pleural effusion and amniotic fluid, etc. Among more than 4.5 million notifiable diseases reported in China every year , a large majority of diseases are transmitted through the respiratory tract, blood and body fluid, etc. Amid these biological factors, it is most common for nurses to be injured by sharp objects, especially needles, and then infected by diseases transmitted through blood . During needle injury, only 0.004ml blood with HBV is enough to infect the injured person  .
1.3 Physical hazards:
With the scientific development and improving operation, intraoperative photograph and operation under roentgenoscopy have been widely practised. As proven in the data, X-ray may induce the gas ionisation in air, generating some harmful substances including nitrogen compounds, ozone and free radicals, etc. If being exposed to little X-ray frequently, the effect of accumulation can cause cancer or fetal malformation . The operating room is also exposed to severe noise pollution, such as, sound from application of various instruments and equipment during operation, conversation among workers, noises caused by objects moving, and friction sounds between wheels of instruments on the floor, etc. In the operating room, nurses have to work in a noisy environment, which is inevitably harmful to their neural system, cardiovascular system, endocrine system and auditory system. During use of aged or improper use of equipment, nurses may experience electric shock and injury.
1.4 Physiological hazards:
The work in the operating room is one of fast tempo, long duration, high risk and relative irregularity, which place workers under stress all the time. If there is a major operation, nurses must work uninterruptedly for a long time, so they have meals irregularly, resulting in gastrointestinal diseases. To assist the operation, nurses need to bend their heads constantly, which easily causes cervical spondylosis. Also, nurses have to stand during operation, so their waist is constantly stressed, resulting in lumbar muscle degeneration, pain in low back and legs, and varicose veins of lower extremities. Moreover, some accidental injuries, including bruise, being hit by heavy object, injury by sharp objects, etc. are also important hazards to nurses.
1.5 Chemical hazards:
As the operating room has a relatively enclosed environment, chemical hazards are mainly chemical disinfectants used extensively and the anesthetic waste gas remaining in air. In the operating room, nurses are exposed to chemical disinfectants. If they are not well protected, nurses may suffer from rhinitis, keratitis, shortness of breath, headache, contact dermatitis, arthralgia, asthma, disorder of memory, lack of concentration and reproductive system diseases . If exposed to a small quantity of volatile anesthetic for a long time, people may experience decline in memory, miscarriage, fetal abnormality and diminished fertility . Apart from that, there is smoke generated by the electrical knife during use; volatile gas of burnt ointment, use of antineoplastic drug during operation and various embedded fill materials, such as bone cement and bone bonding agent used in orthopaedics. As surveyed, more than half of them have irritating effect on the human body, especially materials containing acrylate. In their study, Smith and other persons discovered that the aforesaid materials easily cause swelling and redness on skin, tactile allergy or peeling, etc., and even allergic reaction or asthma in severe cases.
1.6 During operation:
Nurses often work for six to eight hours, standing for a long time. Also, they have to walk around quickly to move packages of devices and auxiliary materials, as well as wash and deal with all kinds of machines and heavy objects. Scrub nurses has to stand for a long time continuously, up to 6.5h per day or longer in some cases. Circulating nurse must walk at a speed of 240 paces/minute on an average for four hours /day or longer. As nurses are under heavy load, the incidence of spinal injury and lumbosacral pain is 8.4%. The varicose veins of lower extremities happen much more often on nurses than other professions due to long-time standing.
1.7 Noise hazards:
The noises in the operating room are mainly produced by electric drill, electric knife, negative suction, anesthetic apparatus and blood pressure detection system, etc. If people stay in a noisy environment for a long time, they will experience headache, insomnia, hearing loss and elevated blood pressure, etc., and may also lose their temper and concentration, easily making mistakes at work.
1.8 Eye damages:
Under the long-term effect of strong light, eyes will be tired. When ultraviolet ray is used for air disinfection, nurses who are not well protected will develop keratitis and conjunctivitis.
1.9 Influence of X-ray:
In new practice of orthopedic operation, C-arms are used more and more often. In keeping contact with a tiny quantity of X-ray frequently, nurses will face damages to organisms (leucopenia, abnormal procreation and radiation diseases, etc.).
1.10 Adverse effects of anesthetic gas.
In the operating room where nurses work every day, there is a low concentration of volatile chemical disinfectant and remaining inhaled anesthetic. Some inhaled anesthetics, e.g. enflurane, nitrous oxide and ether, but these can only be excreted after a long time if they are inhaled into the human body. If exposed in the environment contaminated by a small quantity of anesthetic gas, a nurse may suffer from miscarriage, fetal malformation and diminished fertility.
2. Protective Measures
2.1 Protection against socio-psychological hazards:
Nurses working in the operating room should strengthen the awareness of self-protection. In the meanwhile, they should also actively adjust their attitude, learn more about their work and improve their own professional skills. Nurses should often pay attention to getting familiar with the categories of operation and the habits of surgeons, visit the patient before operation and get everything ready for operation. During operation, they should know every step clearly, and cooperate with one another in a coordinated and orderly manner. After operation, nurses should sum up their own work and keep notes of operation if necessary. In addition, the operating room should be kept well ventilated to create a relatively comfortable environment for nurses working. During operation, some gentle music can be played. A comfortable and elegant place for rest and environment for dining should be set apart for nurses working in operating room. All these are positive for nurses who can have good psychological quality and reduce mental pressure. Nurses should arrange their tempo of life, properly deal with the relations between their professional role and the role they play in daily life, and gain the understanding and support from families.
2.2 Protection against biological hazards
2.2.1 Strengthening protection:
The test and examination system before operation should be improved, and any positive results should be indicated on the notice of operation. Nurses working for operations should be arranged for duty reasonably. If a patient has positive result in blood biochemical test, nurses with infection in the upper respiratory tract, wound on hand or skin disease shall not be arranged for duty for the operation . Before operation, nurses should visit the patient and know clearly the patient’s condition, e.g. patients with HBV, HIV, syphilis and other special infections. Nurses should get ready for such operations in advance. Nurses should wear goggles and mask, special protective shoes and double-layer gloves. As proven in studies, if a needle penetrates through the glove and into the skin with elasticised two-layer glove, its depth into the skin will be reduced, so less blood enters the skin, reducing infection rate to only 0.2%~0.25%. Nurses should have the habit of washing hands frequently. A survey shows that if a nurse does not wash hands after contacting a patient or contaminant, the rate of carrying bacteria on hands is 100%. In addition, inoculation should be well carried out, and department of infection control should provide periodic physical examination for nurses working in operating room. These preventive measures are very important.
2.2.2 Standardize procedures:
Nurses should pay attention to washing hands before operation and wearing gloves. During operation, nurses should not directly mount or demount blades, or pass around needles, knives, scissors and other sharp objects, but handle them with trays instead. For a patient with special infection, bending trays should be used to handle sharp instruments, in order to reduce injuries. During operation, nurses should be well concentrated, pay close attention to theoperation, work fast and pass instruments accurately. After the operation, nurses should be careful and cautious to place sharp tools inside boxes and wash instruments with protection.
2.2.3 Treating injuries:
If wounded by any sharp tool during operation, the nurse must squeeze out blood around but not at the wound, wash the wound with flowing water, and then wash it with 0.5% iodine. Within 24 hours, the nurse should report this condition to the hospital’s department of infection control. If necessary, the nurse should receive an injection of hepatitis B immune globulin. If exposed to blood or body fluid with HIV infection, the nurse must immediately receive a hazard assessment to determine whether medicine is needed, and take periodical examination of HIV antibody (6 weeks, 12 weeks and 6 months, etc.). During periodical examination, the nurse should not donate blood or body organ, or breast feed, and must use protection during sexual intercourse.
2.3 Adjust workload of nurses:
The cumbersome preparation for operation, which is burdened by two nurses on the night shift, is allocated to six nurses on the day shift, significantly reducing the workload of nurses on the night shift. We should also persist in the practice of replacing scrub nurses after 14:30 every day to allow them to rest well, which improves the work efficiency. Considering that instrument nurses spend much time and energy on preparation for operations on the next day and sometimes receive complaints from surgeons, we prepare a suite of common instruments to help nurses know clearly about instruments needed for operations on the next day, which reduces blindness and randomness in preparation, saves the time for preparation and alleviates the pressure on nurses.
2.4 Wear protective goggles, waterproof mask, disposable gloves, waterproof gown or disposable apron under gown:
Nurses should protect their feet against any falling instruments. Brushes should move under water while cleaning instruments to prevent water from spraying onto clothes, operation table and even on one’s own body, which may cause cross infection. Nurses should wear veils while flushing any instrument with tubular cavity. During flushing, the tubular cavity should face down backwards to prevent water from directly hitting the sink wall, which may carry blood, sputum and other fluids inside the tubular cavity onto the wall and bouncing back onto the face of the nurse, especially the eyes.
The basic guarantee for good nursing is that nurses can protect their own health well. This paper studies related issues including all kinds of hazards in operating room, and proposes some corresponding protective measures. We hope that the management of hospitals and departments can fully understand the importance of nursing and pay more attention to nurses, establish and improve the protective system for nurses, strengthen the education and publicity regarding prevention of occupational hazards, develop and improve their protective measures, help nurses get correct understanding of and keep in mind protective actions, reduce occupational hazards, and protect the physical and psychological health of nurses, so as to guarantee the quality of nursing.
 Li K. Occupational exposure and protective measures for nurses. Chinese Journal of Nursing. 2008;43(6):571.
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