Active Research
Work-Related Injuries and Burnout in Sonographers

Objective. Supporting sonographers’ health and well-being requires targeting the workplace factors they identify as most influential. This study examined sonographers’ perspectives to guide priorities for resource allocation and solution development.

Materials and Methods. An online survey of 1276 U.S. and Canadian sonographers asked participants to rate 30 workplace factors across four categories—workflow, equipment/physical environment, administrative/organizational environment, and training/health practices—on their perception of impact on well-being and importance for understanding and improving. Respondents selected up to five factors as the highest priorities for immediate action and resource allocation.

Results. Five factors ranked among the top 10 across specialties and were rated as significantly impactful and important by more than two-thirds of respondents: productivity requirements (76.9% impact, 74.3% importance), staff scheduling policies (73.2%, 74.4%), supervisor support (72.1%, 71.2%), exam room furniture (73.1%, 68.0%), and ultrasound machine design (69.3%, 75.6%). Exam scheduling was the top priority across all practice areas and the only factor identified in the top five by a majority of all respondents.

Conclusion. While specialty area differences exist, sonographers consistently identified administrative and organizational factors as the most impactful, important, and of highest priority for immediate action. Addressing these concerns requires contextualized solutions developed with direct practitioner input.

A virtual participatory workshop was held to address the issue of prioritizing image quality over the risk of work-related musculoskeletal injury (WRMSI) and burnout. The data that were collected from the session was analyzed qualitatively to discover the possible factors that could negatively affect the quality of sonographic examinations, without blaming the sonographer. The capture of rich discussion centered on the need to strike a proper balance between a high-quality sonogram without contributing to negative effects to a sonographers’ health and safety. As a sonographer’s health declines, the physical abilities and cognitive focus required to perform one’s best also declines, resulting in lower overall quality and a downward spiral of declining health and quality. Identifying solutions to maintain a proper balance between image quality and sonographer health and safety is paramount. To successfully implement and maintain workplace solutions, sonographers, clinic staff, and administrators must work together to determine which solutions can be trialed in the workplace. Further practical research is needed to quantitatively measure some of the key themes from the workshop: the need for structural change to reinforce the necessity of WRMSI risk reduction, ongoing prioritization of quality over WRMSI risk reduction, and an urgent need to teach students WRMSI risk reduction.

Objective. Burnout in sonographers is a prevalent and complex professional hazard associated with poorer quality of work life, productivity, and patient outcomes. This study aimed to understand the prevalence of and work systems factors associated with burnout among a large sample of sonographers.

Materials and Methods. Research study registry participants (n = 3659) were invited to complete a follow-up survey about personal and work environment factors, including work hours, break time, coworker and supervisor support, and job satisfaction, overall health, and sleep quality. The Copenhagen Burnout Inventory assessed personal, work-related, and client burnout. Simple and multiple linear regressions were used to identify work systems factors associated with burnout.

Results. Of 1389 respondents, over half reported moderate-to-severe personal and work-related burnout, while one-quarter reported moderate-to-severe client burnout. Higher work-related burnout was associated with younger age, working in the Western United States, working full-time, taking fewer weekly break hours, poorer overall health and sleep quality, and lower supervisor support and job satisfaction. Client burnout was associated with poorer sleep quality and lower job satisfaction.

Conclusion. Burnout was prevalent in a large sample of sonographers. Multilevel work systems factors are associated with burnout, suggesting collaboration among sonographers, administrators, and organizations is needed to address burnout.

Objective. Work-related injuries have a major effect on worker health and well-being. This is particularly true in sonography, where work-related musculoskeletal disorders (WRMSDs) are common. In response to the current challenge of understanding strategy implementation across social and organizational dimensions, this research captured sonographers’, echocardiographers’, and vascular technologists’ perceptions of critical administrative, organizational, and general health and training challenges, and potential solutions for improving worker health and well-being.

Materials and Methods. A survey invitation was sent to the WRMSD Grand Challenge longitudinal study registry participants. Open-ended questions on the online questionnaire allowed respondents to share comments, ideas, or potential solutions to improve worker health and well-being regarding the administrative and organizational environment or through training and general health interventions. There were 377 free-text responses that were qualitatively analyzed using a grounded theory approach to generate overarching themes and identify emerging theory, supported by initial coding, focused coding, and reflexive memoing. A member check was conducted by interviewing four participants to refine and confirm the findings.

Results. Five themes were identified: “Limits and Guidelines,” “Injury Education,” “Ergonomics Training Constraints,” “Resources and Equipment,” and “Individual Habits.” Participant suggestions within these themes were categorized and mapped onto a sociotechnical systems model that was developed previously to study the healthcare system(s) in which sonography users work. This conceptual mapping revealed how these solutions were situated to impact different levels of the work environment. The themes and mapping supported an emerging grounded theory: Risk Reduction Relies on Proper Employee Representation.

Conclusion. These qualitative findings align with contemporary guidelines and recommendations for mitigating injuries in sonographers, illuminating challenges and solutions targeting levels of influence beyond the staff sonographers’ scope. The need for representation of sonographers at higher-level administrative levels has not heretofore been addressed by WRMSD guidelines.

Objective. Explore the differing associations of Sonography Work Systems (SWS) model factors with work-related discomfort outcomes among sonographers in four sonographic practice areas.

Materials and Methods. Survey data from a national cross-disciplinary cohort of sonographers was analyzed to explore experiences of work factors and work-related discomfort in sonographers across four practice areas: abdominal (ABD+), adult echocardiography (Echo), obstetrics/gynecology (OB/GYN), and vascular technology (VT). One-way analyses of variance (ANOVAs) and chi-square tests were conducted on SWS factors and work-related discomfort to examine differences across practice area groups. Associative analyses were conducted between upper extremity musculoskeletal discomfort and hand used during sonography examinations. For each practice group, regression analyses examined associations of SWS factors with work-related discomfort (i.e., musculoskeletal and visual discomfort, headaches).

Results. 2924 survey respondents (n = 1747 ABD+, n = 519 Echo, n = 351 VT, and n = 307 OB/GYN) were identified. Descriptive differences were identified in SWS factors and discomfort across practice area groups. Significant differences were noted in distribution of upper extremity pain compared with the hand used to complete sonography examinations (P < .001).

Conclusion. This study identified multiple organizational, tool, and process factors commonly associated with discomfort across specialties, which underscores the need for multidimensional approaches to worker health that include effective administrative and engineering controls.

Objective. This work aimed to explore how the COVID-19 pandemic affected the work of sonographers and vascular technologists.

Materials and Methods. A follow-up questionnaire was sent to an established registry of ultrasonography users who opted into a longitudinal research study examining worker health and wellbeing. Multiple questions related to the general impacts of COVID-19 on sonography work practices, workload, and considerations of remaining or leaving their current job were included; responses to these questions were descriptively tabulated. Participants indicated specific changes that occurred and provided general comments related to COVID-19 impacts in two free-text questions. These comments were qualitatively analyzed by two sonographers who used an interpretive grounded theory approach to formatively code and memo the comments. Four summative interviews were conducted with participants who represented varied practice areas to gain deeper insights into the experiences expressed by the total respondent pool. Qualitative coding of the free-text responses and interview transcripts was completed independently by the two sonographers using the Sonography Work Systems (SWS) framework, and the full research team contributed to the interpretation of the findings.

Results. A total of 1389 ultrasonography users completed the questionnaire. The pandemic changed the ways in which examinations were performed for approximately half of the respondents. A higher or somewhat higher workload was noted by 48% of the sample, while only 10% experienced a lower or somewhat lower workload. Components of the work system were a major concern for respondents, and a lack of support from supervisors and hospital administration was a key finding. Participants felt limited in their ability to provide care, experienced posttraumatic stress, and reported a lack of reciprocity, which were all underscored as undesirable outcomes.

Conclusion. Sonographers and vascular technologists suffered negative consequences during the COVID-19 pandemic. The most marked outcome was the undesirable effects on the work system, which resulted in the need for these workers to engage in herculean efforts over a sustained period. Findings suggest that these health care heroes may have experienced physical and mental harm while trying to provide health care services, despite numerous institutional challenges.

Objective. Work-related discomfort is a pervasive issue among ultrasonography users. The Sonography Work Systems (SWS) framework was constructed as a means of examining relationships within and across components of the sonography work systems, work processes, and work/worker outcomes. A database of ultrasonography users was established as a foundation for a longitudinal survey study to examine worker health and well-being and explore the most salient work systems and process factors associated with work-related discomfort.

Materials and Methods. An estimated 100 000 unique ultrasonography users were invited to complete the online questionnaire through an e-mail campaign. Snowball sampling occurred through social media posts and encouragement for respondents to share the survey link with colleagues. The questionnaire included items that examined participant demographics, selected constructs from the SWS, and the prevalence of work-related musculoskeletal discomfort, visual discomfort, and headaches. Individual and multi-factorial regression models were conducted to examine SWS factors associated with the likelihood of experiencing the three types of work-related discomfort.

Results. A total of 3659 valid responses were included in the analysis, with 86% of respondents reporting that they regularly experienced musculoskeletal discomfort that they directly attributed to their work. About half (54.2%) of the respondents have engaged in sonography-related ergonomics training, and respondents indicated using adjustable equipment approximately 74% of the time. Workplace culture was rated as primarily positive, but respondents indicated that employers implement only two of seven commonly recommended ergonomic policies and procedures. Working in an organization with more policies, using adjustable equipment more frequently, taking more work breaks, engaging in a positive work culture, and minimizing interruptions to workflow were key factors associated with reduced likelihood of work-related discomfort.

Conclusion. This study provides a new framework for examining and addressing factors that contribute to ultrasonography users’ experience of work-related discomfort. Despite increased participation in ergonomics training and the use of adjustable equipment, the prevalence of work-related discomfort remains high among ultrasonography users. The findings highlight the need for attention to be directed at organizational factors and work processes to identify and implement evidence-based solutions to improve the health and well-being of medical ultrasound users.

The prevalence of Work-Related Musculoskeletal Disorders (WRMSDs) among ultrasound professionals has been significant. National and international efforts to create industry standards have focused primarily on injuries in sonographers. In addition, the Centers for Disease Control and Prevention (CDC) and National Institute for Occupational Safety & Health (NIOSH) have published documents related to this occupational exposure. There has also been significant attention on equipment utilization and design to help reduce the prevalence of WRMSDs. The American Institute of Ultrasound in Medicine (AIUM) developed the AIUM Practice Principles for Work-Related Musculoskeletal Disorder in collaboration with other organizations whose members use ultrasound [see Collaborating Societies and Representatives]. This document supports the “Industry Standards for the Prevention of Work-Related Musculoskeletal Disorders in Sonography” and aims to expand on these Standards to include safety practices for all health care professionals who utilize ultrasound. These professionals include members of the scientific community, a wide variety of medical professionals, and dental professionals. These ultrasound users and operators will collectively be referred to in this document as “operator(s)” except in those instances where data addressed those holding a specific job title, such as sonographer. In addition, this document will support guidance for quality improvement specific to preventing and reducing injury rates.

Keywords. Ergonomics; occupational exposure; work-related musculoskeletal disorders; WRMSD

This article discusses the importance of conducting a longitudinal data collection concerning well-being and the risk for work-related musculoskeletal injuries (WRMSI) among sonographers and vascular technologists. There is a need for changes in the manner that sonographic work is done, but this should be nested in empirical evidence. This gives the rational for conducting the study titled Documenting the overall wellness of ultrasound users and the risk of progressive WRMSI: A national longitudinal study. The objective of this longitudinal work is to better understand collective practice patterns and examine the relationship of sonographic work conditions and performance to the user’s health and well-being. This symposium provides the foundational understanding of the strength of this type of study and how it may help to influence behavior and organizational change.

Background. There is a significantly high rate of work-related musculsokeletal injuries in sonography professionals. To date, assessment of risk factors for work-related injuries in sonographers has been based primarily on surveys, subjective reports, and observational methods. There is a need to develop quantitative techniques to better understand risk factors and develop preventive interventions.

Objective. We pilot tested a high-resolution force-measuring probe capable of precisely measuring forces applied through the transducer by sonographers and used this novel direct measurement technique to evaluate forces during abdominal imaging.

Methods. Twelve sonographers with varied experience, ranging from 1-33 years, performed routine abdominal scans on 10 healthy volunteers who had varied body mass indices (BMI). Imaging was conducted using the force-measuring probe, which provided real-time measurement of forces, and angles. Data were compared by sonographer years of experience and subject BMI.

Results. In total, 47 abdominal examinations were performed as part of this study, and all images met standards for clinical diagnostic quality. The mean contact force applied across all exams was 8.2±4.3 Newtons (N) (range: 1.2-36.5N). For subjects in the high BMI group (BMI>25, n=4) the mean force was 10.5N (range: 8.9-13.2N) compared to 7.9N (range: 5.9-10.9N) for subjects with normal BMI (BMI=18.5-25, n=6). Similarly, the mean maximum force applied for subjects with high BMI (25.3N) was significantly higher than force applied for subjects with normal BMI (17.4N). No significant difference was noted in the amount of force applied by sonographers with more than 5 years of experience (n=6) at 8.2N (Range: 5.1-10.0N) compared to less experienced sonographers (n=6), whose forces averaged 8.1N (Range: 5.8-10.0N).

Conclusions. It is feasible to directly measure forces applied by sonographers using a high-resolution force measurement system. Forces applied during abdominal imaging vary widely, are significantly higher when scanning subjects with high BMI, and are not related to sonographer years of experience. This force measurement system has the potential to provide an additional quantitative data point to explore the impact of applied forces on sonographer related musculoskeletal injury, particularly in conjunction with various body positions, exam types and force durations.

Background. Musculoskeletal pain and discomfort due to work exposure is experienced by 90% of sonographers. Survey research has provided a wealth of information to document this problem, but few studies have attempted to directly measure and identify the source of these disorders.

Objective. This pilot observational study was conducted to obtain direct measures of the relationship of sonographers to their environment during the completion of sonographic examinations.

Methods. The Rapid Upper Limb Assessment (RULA) was used to evaluate the positions of five sonographers during 24 sonographic examinations. The observed positions were compared among the various examinations and the association of these observed postures to discomfort, sonographer height, and exam table height was evaluated.

Results. All participants reported an increase in musculoskeletal discomfort at the end of the workday. Overall RULA scores ranged from 3.11 to 5.00 with upper extremity venous Doppler and transvaginal pelvic examinations averaging the highest. Increasingly poor upper extremity positioning was positively associated with increased musculoskeletal discomfort (r = 0.53, p < 0.01).

Conclusions. Regardless of the examination being performed, sonographers are working in positions that require further evaluation and intervention. Longitudinal studies are needed that evaluate the inter-relationship of biopsychosocial risk factors of musculoskeletal injuries.

Objective. Three-fourths of diagnostic medical sonographers (DMS) and vascular technologists (VT) experiencing discomfort due to job demands indicate having discomfort in the shoulder region. An analysis of factors related to shoulder discomfort highlighted salient factors requiring further investigation and intervention.

Methods. The responses of 2,163 DMS and VT from a survey of a representative sample were analyzed to determine personal factors, work demands, and workstation design characteristics of those experiencing discomfort in the shoulder region. Frequencies and response distributions were calculated and cross tabulation with chi-square analysis was completed.

Results. A majority of respondents with shoulder discomfort have co-morbid reports of discomfort in other locations. While overall sonographer discomfort is linked to age and years of experience, shoulder discomfort was also noted to be linked to specific workstation characteristics. A lack of adjustability in equipment, PACS workstations, and positions required to complete bedside exams contributes to discomfort due to sustained and repetitive shoulder abduction and twisting of the neck and trunk.

Conclusions. There is a need for studies investigating redesign of equipment and workstations or interventions with DMS and VT specifically focused on improving adjustability and improved positioning of sonographers in order to reduce shoulder discomfort while performing job demands.

A cross-sectional representative sample of 1722 sonographers and vascular technologists was analyzed using quantitative/qualitative methods to reveal that 60% are experiencing wrist-hand-finger discomfort, believed to be from work-related repetitive injury. The years of scanning accumulated by the participants was chosen as a variable to determine the relationship to the range of discomforts reported. A strong statistical correlation was noted between years of experience and the side of discomfort as well as the severity of hand-wrist-finger discomfort. In this study, a strong statistical association was also noted between increasing years of scanning and decreasing aggravation due to the transducer. A complete linkage between work-related exposure and hand-wrist-finger discomfort is difficult to make because of the contribution of leisure-time activities. A controlled experimental study is needed to determine the contribution that grip and pushing on the transducer may have on the incidence of hand-wrist-finger discomfort, leading to diagnoses such as carpal tunnel syndrome.

A pilot study was conducted to gather holistic data points on female sonographers who executed neonatal neurosonography over four portable scanning sessions. The hypothesis was that specific risk factors contributed to work-related musculoskeletal distress in the hand and wrist as a result of neonatal neurosonography. A preexperimental pre-post research design was used to gather data on work demands, self-rated physical and mental health, posture/position during scanning, physiologic change, and pain scores. No statistically significant changes were detected between pre-post measures for work demands, physical and mental health, or pain scores as a result of portable scanning sessions. The physiologic changes, between scanning sessions, were recorded with the use of a hand-carried sonographic unit. Sonographic measures were less than the published criteria for carpal tunnel syndrome with a proximal cross-sectional area ≥10 mm² and an anterior bulge of the retinaculum of >4 mm. Sonography documented a statistically significant cross-sectional area change, within the median nerve, at the distal radius only after the first scanning session. Power and spectral Doppler was used to document perineural vascular flow within the median nerve, but it was not consistently obtained to allow for a rigorous comparison between pre- and post-scanning sessions. This is the first pilot study to explore using a hand-carried sonographic unit to document change in the median nerve for an isolated sonographic examination. The results are only reflective of these particular participants, but much larger N and shorter scanning sessions are needed to confirm the hypothesis proposed.

Literature indicates a significant history of workr-elated musculoskeletal disorders (WRMSD) among diagnostic medical sonographers (DMS) and vascular technologist (VTs). To gather current data related to this historical trend, the authors administered a survey to a random and convenient sample of 5200 registered DMS and VTs. The invitation to complete the survey on a secure Web site yielded the largest participant sample to date of 2963 completed surveys (57% response). Data relative to the prevalence of WRMSD were analyzed and compared to other WRMSD research over the past decade. Results indicated that 90% of respondents were scanning in pain, a 9% increase since the last large scale survey in 1997. Across all demographics, shoulder pain is most common, with older and more experienced sonographers having more finger, hand, and wrist pain than other groups. Pain continues to be related to pressure applied to the transducer, abduction of the arm, and twisting of the neck and trunk. Ergonomic equipment and education are provided by application specialists, but the incidence of WRMSD appears to be unabated. Higher order research, including randomized trials, with education and ergonomic interventions is needed to protect DMS and VTs who are necessary to meet increasing health care demands.