Human Factors & Ergonomics Society of Australia 42nd Annual Conference 2006 1
Dr Janet Sawyer
Business and Regional Enterprise, University of South Australia
Ms Joy Penman
Nursing and Rural Health, University of South Australia
Keywords: ergonomics, nursing practice, occupational health and safety, computer use
ABSTRACT
Nurses have had to grapple with the increasing use of technology, including the use of computers, within their profession. This research investigates whether the ergonomic principles relevant to computer use are known and applied by Nurses as they carry out their everyday activities. Registered nurses working in various health care facilities were surveyed to determine their level of awareness and knowledge of ergonomics and the priority nurses and the health organisations give to safe computer use. The majority had not received training in this area from their organisation or from an educational institution. They were generally aware of good sitting posture but not of the appropriate layout and positioning of computer equipment. There was also a good understanding of the role of rest breaks. Many respondents did not know whether their organisation had a written policy relating to ergonomics and computer use. The findings indicate that greater education and management commitment is required to develop healthy computing work habits amongst nurses.
1. INTRODUCTION
Nurses, along with other professionals, have needed to respond to the rapid and continuing changes in the use of technology. The nursing profession has dealt with the information explosion by becoming specialists or non-traditional nursing practitioners in a narrower field of practice. Regardless of specialty practice, acute or chronic clinical care, teaching, research, or community practice, nurses use computers in their daily routines at work and are increasingly pressured to become computer literate and embrace the technology to their advantage.
The application of ergonomic principles in computer use by nurses has not been adequately studied. The aims of this research were to determine the level of awareness and knowledge of the principles of ergonomics that relate to computer use amongst practising nurses; to examine the priority given to ergonomic principles by practising nurses; to ascertain the responses of organisations to ergonomics for computer users; and to explore how nurses might be assisted in understanding the principles of ergonomics relating to computer use.
As an approach or philosophy, ergonomics has been used to guide the way the workplace is designed and organised. The guiding principle is providing for workers an environment that is ‘people friendly’, where working techniques are improved, errors, accidents and injuries are reduced, and work satisfaction, efficiency and productivity are increased.
In applying ergonomic principles to computer use, key issues relating to optimal human interaction with computers include the physical layout of the computing environment, seating, lighting levels and sound levels (Harper 1991, p 39). However, Patkin (cited in Moore 1990, p 45) noted that, while having a suitable environment and well-designed furniture and equipment is important, it is also important that people “know how to use it correctly and incorporate it into the total work place system”. Both employee and employer have responsibilities for a safe workplace - the provision of a safe work environment on the part of employers and the application of safe work practices on the part of employees.
It is generally acknowledged that prolonged computer use may result in visual, musculoskeletal and psychological problems. Typical physical complaints affecting the musculoskeletal system include: eye strain, pain in the neck and shoulders, arms, elbows, wrists and fingers, lower back or hip pain, pain down

Human Factors & Ergonomics Society of Australia 42nd Annual Conference 2006 2 the leg, swollen ankles, and pain in the foot and/or toes. Typical neurological and psychological complaints include: headaches, fatigue, and stress from too much work to do or too much information to process within a limited time period. In addition to suffering the health condition, these have cost the individual in terms of medical expenses, lost career opportunities and reduced quality of life, and organisations in terms of days lost, impaired work performance, reduced productivity and increased compensation claims (Grandjean 1987).
Strategies for the prevention of computer-related disorders must be based on redesigning the work and systems so that factors identified as causing health problems can be eliminated (P ublic Service
Association of South Australia 1990, p 40). Prevention of problems must take into account the chairs and equipment used, work surfaces, keyboard use, posture, lighting, temperature and work flow of work area, rest breaks, software ergonomics, job design, and job training. Cost-effective solutions for computerrelated disorders reported in the literature include: appropriate distance from visual display unit; correct lighting conditions; correct optical prescription; appropriate head position, sitting posture and positioning of the arms and wrists; adequate rest; arms supported; correct chair adjustment; support of lumbar spine; adequate padding or styling; good leg position; feet on the floor or supported by an appropriate foot rest; and room for movement. Information on prevention of computer-related health problems can be obtained from the literature of Cook and Burgess-Limerick 2003, Cook and Kothiyal 1998; Doheny, Linden and
Sedlak 1995; Peper and Shumay 1996; Quibble 1996; Worksafe Australia 1996; and Wright and Wallach
1997.
Technology and the practice of nursing are intimately related. From heart-lung machines, palm-held computers, digital technology, SMART cards, telemedicine, electronic medication management, and robots, to at-home monitoring of the patient, the definition of nursing is expanding to include being knowledgeable and proficient in using technology (Bower & McCullough 2004).
The Internet, “the largest, most powerful computer network in the world”, is allowing nurses to access quickly relevant and useful information (Sansoucie 2000, p 2). “Technological applications are being increasingly used to expand access to continuing professional education, facilitate communication networks, and obtain the most current clinical information” (Sansoucie 2000, p 1). The instructional delivery of distance education has drastically changed, increasing information access for key stakeholders, namely students, faculty and clinicians.
Teaching and learning have been revolutionised by technological advancements. The worldwide web has enabled access to information on clinical guidelines and standards, various health conditions, educational institutions offering continuing education, and patient education materials. Teaching and learning have evolved to include web-based research, student conferencing via electronic discussion groups, chat rooms and electronic mail.
In nursing practice, computers play a major role in facilitating communication between nurses. More importantly, they allow nurses to gain and track information about patients (Bell 1999). Bower and
McCullough (2004) argue that automation and the use of technology is becoming part of a comprehensive strategy to address nursing needs. These authors focus on the need to provide nurses with the tools and the skills used by other professions so that they can deliver quality care using the most-up-to-date technology available. While computers have been available to health care personnel since the seventies, many nurses lack computer literacy and access to information technology (Pravikoff 2005).
2. METHODOLOGY
A descriptive and empirical approach was used in this research. A sixteen-item survey instrument was developed and distributed to practising nurses through the heads of a regional hospital, the school of nursing in a metropolitan and a regional university campus, an aged care facility and two doctors’ surgeries located in a regional area.
Sample. Registered nurses currently practising in various capacities at different health care facilities were recruited for this study. A list of the health care facilities in the regional city and the number of nursing staff in each was compiled. From this list the total population was determined to be approximately 174. The sample included nursing lecturers working in a metropolitan and a regional university campus. It also included nursing staff in doctors’ surgeries, recognising that these nurses are increasingly using computer technology in tasks such as health care planning and maintaining client records. Following approval from the health care facilities and schools of nursing, a total of 140 letters and questionnaires were distributed.

Human Factors & Ergonomics Society of Australia 42nd Annual Conference 2006 3
Data Collection. The questionnaire used was based on an instrument developed and previously validated by the first author. It collected data relating to demographics; awareness of ergonomic principles; educational and training sessions attended; knowledge about organisational policy on procedures related to ergonomics; ability to recognise poor positioning; taking rest breaks from the computer; and perception of sufficient priority given within the organisation.
Procedure. Written approval from participating organisations was obtained before commencing the research.
Introductory letters were distributed which contained the purpose and procedures of the study and the expected benefits of the research. Purposive sampling was used to select participants who shared common experiences or characteristics. The selection criteria were that the person was currently registered with the Nurses’ Board of
South Australia, practising a nursing speciality, and had consented to participate in the study.
Data analysis. The data collected were coded and entered into the Statistical Package for the Social Sciences
(SPSS) (Norusis 1990). Descriptive and frequency analyses were performed for all variables.
3. RESULTS
Of the 140 survey instruments distributed, 52 completed questionnaires were received giving a response rate of 37%. Details of the organisations surveyed and the respective response rates are given in Table
1.
Table 1 Number of Questionnaires Returned and Response
Rates
Type
Of Organisation
Maximum
Possible
Response
Actual
Response
Percent
Returned
Doctor’s Surgery
Community Health
5
15
2
4
40
27
The majority of the subjects were female, clinicians, and aged between 38 and 47 years, which reflects the current nursing workforce that is composed predominantly of middle-aged females (Armstrong 2004;
Australian Health Workforce Advisory Committee 2004). The various positions reported reflect the expanding roles of contemporary nurses; while the majority were clinicians, nurses have extended their roles in education, research, management, community health, and surgeries.
The estimated daily use of a computer ranged from 15 minutes to 10 hours per day, with an average of
3.5 hours depending upon the speciality the nurse was engaged in. Clinicians reported that they do not spend much computer time in an average day while a lecturer or manager may require more time with computers. However, 33% of respondents used a computer for more than 4 hours per day which is a considerable length of time in terms of the need to be aware of, and to apply ergonomic principles to computer use if workplaces are to be efficient and safe (Public Service Association of South Australia
1990).
Respondents were asked whether they were aware of the ergonomic principles that relate to the use of computer technology. The majority (61%) indicated they were not aware of these principles. This is not surprising from our perspective because the nursing undergraduate curriculum at the University of South
Australia does not include the topic in any of the courses (University of South Australia 2004). Those respondents answering that they were aware of the ergonomic principles generally indicated that they received their knowledge at work, from occupational health and safety personnel, and from reading various forms of literature containing ergonomic information.
When asked whether they had attended an educational program/training session provided by their organisation that included information on ergonomics and computer use, a large majority of respondents
(79%) replied that they had never attended such sessions. Those who had attended an educational

Human Factors & Ergonomics Society of Australia 42nd Annual Conference 2006 4 program/training session provided by their organisation, were asked how they had applied the knowledge of ergonomics received to their work situation. Most respondents did not answer this question; responses were received from only 12% of all respondents, suggesting that ergonomic principles were rarely being applied to computer use.
The majority of respondents learnt their computer skills on the job (50%) rather than via study at an educational institution (27%). Other respondents replied that they learnt to operate a computer at home and were self-taught or “taught by the kids”. 85% of respondents had not read any documents on ergonomics in relation to the use of computers in the last 12 months. This finding suggests that information on ergonomic computer use is not readily available within workplaces or the wider community.
Two questions, each containing five photographs depicting various scenarios covering work posture and the layout of computer equipment, were used to determine the knowledge of principles of ergonomics related to the use of desktop keyboard-operated computer technology (refer Appendix). Respondents were asked to carefully study each scenario and then indicate whether accepted ergonomic principles were being applied, and to give the reason for their response. A correct response and correct reason were assumed to be indicative of knowledge whereas an ‘unsure’ response, incorrect response, incorrect reason, or a question left blank, were assumed to indicate lack of knowledge.
The responses to the first question in relation to sitting posture and positioning of the arms and wrists indicated that approximately two-thirds of the respondents were aware of poor posture. They generally identified when the seat was too low or desk too high and the elbows too low; when the back was not adequately supported; if the seat was cutting into the back of the knees; and if the body was unbalanced.
It is noteworthy that the lowest percentage of correct responses related to the scenario which illustrated the generally recommended posture and positioning with the back supported, feet flat on the floor, body balanced, head slightly inclined, wrists level, and lower arms and thighs a little more than 90 degrees.
The percentage of correct responses to the second question related to posture and the layout of equipment was considerably less. Only two scenarios were correctly answered by more than half the respondents suggesting that, while respondents were generally aware of when the visual display unit was positioned too high in relation to the computer operator, they were not always able to identify when it was positioned too close or when the document holder was positioned too high. It is noteworthy again, that the scenario illustrating the generally accepted posture and layout of equipment had the lowest percentage of correct responses.
Respondents generally regarded rest breaks as relevant to computer use (92%). Also, when asked how often they should be taken, the highest percentage knew to take rest breaks approximately every 50-60 minutes. However, 25% of respondents either did not answer this question or were unsure. When respondents were asked whether they took rest breaks, it was found that, while most did (59%), a considerable percentage (33%) did not. The purpose of rest breaks is to prevent strain and compression of muscles, nerves and blood vessels which can result in pain and discomfort (Peper and Shumay 1996).
To determine the respondents’ understanding of the purpose of rest breaks, a question was asked about what tasks were undertaken during these breaks. The findings indicated a good understanding of the role of rest breaks, with many responses suggesting physical and non-sitting activities and tasks such as filing and photocopying that would require a change of position and allow the body and eyes to recover.
Responses citing reading and writing, activities that would not rest the eyes and/or the muscles that had been previously used, were very few. Nevertheless, this topic on appropriate activities during rest breaks must be incorporated in educational sessions that might increase awareness and knowledge of nurses on the proper use of computers.
Many respondents (69%) did not know whether their organisation had a written policy relating to ergonomics and computer use. This indirectly informs us that information on ergonomics is not readily available in the workplace. In addition, the majority of respondents (58%) believed ergonomic principles relating to computer use were given insufficient priority within their organisation. The challenge here is how to entice organisations to give priority to ergonomic computer use because unless they take this up, employees will not consider this important.

Human Factors & Ergonomics Society of Australia 42nd Annual Conference 2006 5
4. DISCUSSION
The ageing of the nursing workforce necessitates changes in workload and work environment (Blakeney
2005). In referring to American nurses, Blakeney (2005, p 16) says that “it was important to consider how to accommodate older nurses … through the creation of less physically demanding roles; the provision of flexible, reduced schedules; and the use of ergonomics devices to reduce physical strain.”. This is very applicable to Australia’s ageing workforce as well. The application of ergonomics in an ageing nursing population, especially for its members using computers for extended periods, must be given priority by health organisations and the nurses themselves.
Both non-attendance at educational/training sessions provided by their employer and lack of formal computer use training from an educational institution, suggest a lack of exposure to the relevant ergonomic principles and compliance with appropriate ergonomic practices. Also, that only 15% of respondents had read documents relating to ergonomics and computer use in the preceding twelve months further suggests that it is not a priority in health care facilities. Responses to the question asking how knowledge of ergonomic computer use was gained were received from fewer than half of the respondents. This directs us where to intervene, that appropriate information is integrated in work orientation and supplemented by literature for individual study. Even better is the integration of ergonomic principles in one of the foundational courses in the nursing undergraduate curriculum.
The responses to the scenarios relating to posture, positioning of arms and wrists and the layout of equipment indicated that the majority of the nurses surveyed had limited knowledge of appropriate ergonomic practices. Generally the nurses were aware of some good practices relating to posture and body balance but were less knowledgeable about the layout of equipment. Moreover, while many were aware of the need for regular rest breaks and the appropriate duration of breaks, a considerable percentage (33%) reported that they did not take rest breaks at all. Having identified these shortcomings, appropriate education may be provided.
Nurses need to adopt, refine, and use computer technology to their benefit. Kirkman-Liff (2002) points out the opportunity for the nurses to assume a leadership role in maintaining quality health care. In order to achieve this, nurses need to be computer literate and use computers, like thermometers and stethoscopes, as tools of their trade. They need to be knowledgeable about ergonomic computer use. In embracing technology, nurses improve the quality of their practice. It should be underscored that technological advances will not eliminate the need for holistic nursing care, in fact, use of technology complements holistic nursing practice. Moreover, greater management commitment is required if positive attitudes towards ergonomic computer use are to be developed amongst nurses.
Here is where a regional university campus can intervene and provide educational materials and sessions on ergonomics to meet the needs of nurses. Ergonomics and computer use may be offered as a topic in a nursing undergraduate course and to practising nurses as part of their continuing education. Nurses practising in rural and remote communities may often feel marginalised for various reasons when it comes to professional development. Distance, limited or lack of resources, lack of educational institutions, lack of experts and lack of educational experiences and opportunities that may otherwise be present in a different geographical location, are problems rural nurses contend with. The educational sessions on ergonomics may address some of these needs, especially when undertaken on a regular basis and taken up by the health organisation. Collaborating and partnering with health care facilities is a strategic approach in increasing awareness and knowledge of nurses in ergonomics and computer use.
5. CONCLUSION
Literacy has now been redefined not only to include reading and writing but ability to use computer technology. Desktop computer technology has played an increasing role in the workplace for more than two decades. Its applications are enormous. Computers are now an integral part of the health sector and are located in various health care environments. Many of these institutions have computerised nursing care plans and clients’ medical files. Education has been enhanced by computer technology. It is important, however, that health care professionals, including nurses, using computers be aware and committed to the proper use of the equipment considering the health risks that may result following misuse and abuse of computers. Now, more than ever, nurses must have a knowledge of ergonomics.
This research has identified a deficit in knowledge on safe use of computers on the part of nurses employed in various facilities. It can inform educators about the learning needs and support required by nurses in this area and inform managers on the direction to take to better assist nurses. Incorporation of

Human Factors & Ergonomics Society of Australia 42nd Annual Conference 2006 6 the topic in the nursing curriculum will help educate nursing students. Providing ergonomics and computer use as a continuing education course to be delivered by a regional university has been suggested. In increasing awareness about ergonomics and computer use, our research may help enhance available support from organisations and employers in order to address this particular need of nurses. Finally, our study has the potential to create interest in conducting research on the use of technology in the practice of nursing.
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Human Factors & Ergonomics Society of Australia 42nd Annual Conference 2006
APPENDIX
QUESTIONS CONTAINING VARIOUS SCENARIOS
7

Human Factors & Ergonomics Society of Australia 42nd Annual Conference 2006 8

Human Factors & Ergonomics Society of Australia 42nd Annual Conference 2006 9