Combined PLIBEL and RULA assessment of ergonomic risks across 12 operating room nursing procedures: a cross-sectional observational study

Abstract Operating room (OR) nurses face elevated risks of work-related musculoskeletal disorders (WMSDs) due to sustained awkward postures, heavy patient handling, and prolonged static loading. However, procedure-level ergonomic risk profiles across the full spectrum of OR nursing tasks remain inadequately characterized. A cross-sectional observational study was conducted among 25 OR nurses in a tertiary hospital in Baoding, China. Twelve common nursing procedures were systematically evaluated using the Swedish Ergonomic Hazard Identification Method (PLIBEL) for qualitative hazard screening and the Rapid Upper Limb Assessment (RULA) for quantitative risk scoring. Joint angles were measured using Kinovea (version 2025.1.0) motion analysis software to ensure objective RULA scoring. Inter-rater reliability was maintained through dual-assessor evaluation and consensus. PLIBEL identified a total of 243 adverse ergonomic factors across the 12 procedures, with individual procedures ranging from 13 to 25 factors. All procedures shared two common exposures: unsupported standing posture and fatiguing leg work. RULA grand scores ranged from 4 to 7, corresponding to risk levels II through IV. Five procedures achieved the maximum score of 7 (Level IV, very high risk): lateral positioning, prone positioning, postoperative patient transfer, stretcher transport, and equipment transport. These high-risk procedures were characterized by severe trunk flexion, asymmetric leg loading, and external loads exceeding 10 kg. Six procedures scored in the medium-risk range (RULA 5–6), while needle threading scored 4 (Level II, low risk). PLIBEL and RULA findings converged to identify patient positioning and transfer tasks as the highest-priority targets for ergonomic intervention. Adverse ergonomic factors are prevalent across common OR nursing procedures, with patient positioning and transfer tasks posing the most prominent risks. The combined application of PLIBEL and RULA offers complementary strengths—PLIBEL enabling comprehensive hazard identification and RULA providing graded risk quantification—generating actionable, procedure-specific risk profiles that identify the highest-priority targets for ergonomic intervention.