Guidance

Breast screening mammography: ergonomics good practice

Published 22 October 2018

Mammography in the NHS Breast Screening Programme (BSP) is a repetitive task and we must make every effort to reduce the potential for work-related musculoskeletal disorders (WRMSK) for mammographers.

WRMSK conditions are diverse. They affect the musculoskeletal system: bones, joints, muscles, tendons and the tissues that connect them. Across the UK, WRMSK disorders, including back pain, joint injuries and repetitive strain injuries, are the single biggest cause of absence from work.

This guidance includes examples of good practice and recommendations for minimising the risk of injury.

The guidance sets out health and safety legal expectations for employers to protect their staff and to consider WRMSK risks alongside other physical and mental health risks. If musculoskeletal disorders (MSKs) are caused or made worse by work there is a responsibility on the employer to assess the risk and reduce it as far as reasonably practical. See Management of Health and Safety at Work Regulations 1999 regulation 3.

Reasonable adjustments are part of the Equality Act 2010. Employers need to make reasonable adjustments to ensure the health, safety and wellbeing of their employees.

Regulation 14 imposes duties on employees to work safely (as required by Sections 7 and 8 of the 1974 Act), and to inform their employer of:

• anything representing a serious and immediate danger to health and safety
• any matter they would reasonably consider a shortcoming in the employer’s protection arrangements for health and safety

1. Scope and purpose

This guidance encourages all mammographic staff to adopt best ergonomic practice to avoid or minimise harm from work-related injuries within their clinical practice.

This guidance gives clear and detailed information on ergonomics within mammography. It:

• provides a framework to promote best clinical practice to avoid or reduce injury, and for identifying, reporting and resolving problems
• aims to drive continuous improvement in positioning techniques
• promotes the development of a learning culture, effective training and continuing professional development (CPD)
• shares best practice for mammographers working within the breast screening service

The term mammographer includes:

• registered radiographers who are regulated by the Health and Care Professions Council
• mammography associate or assistant practitioners

1.1 Using the guidance

The guidance is specifically aimed at:

• all mammographers in the NHS BSP
• radiography line managers, superintendents and trust health and safety leads
• breast screening unit quality control leads
• professional clinical advisors (PCAs) for radiography
• directors of breast screening
• programme managers

It is also useful for:

• NHS trust managers and employers
• regional screening quality assurance services (SQAS)
• professional bodies
• training organisations and universities
• equipment suppliers

At unit level and individual level, the guidance should be used for:

• induction and training
• self-appraisal and reflective practice to minimise injury
• best practice peer review
• the audit of individual performance and to inform appraisal
• personal development plans and the review of training needs if appropriate
• informing organisational development and business management processes when considering appointments
• informing procurement decisions
• general reference for mammographic staff

At regional level, the guidance should be used by radiographic PCAs to inform:

• the quality assurance (QA) visit audit of unit mammographic performance
• reporting unit mammographic performance at QA visits
• giving support, information and advice to mammographers
• the identification of resource issues for organisational development and business planning processes

Radiographic PCAs should encourage the use of this guidance in the everyday working practice of breast screening mammographers.

The guidance should be considered in conjunction with other relevant guidance and regulatory frameworks. These include but are not limited to:

• relevant Society and College of Radiographers guidance
• Health and Care Professions Council Standards of Conduct, Performance and Ethics (for registered radiographers)
• trust manual handling protocols and policies

The guidance is aimed at the English breast screening programme but may be helpful for mammographers working in the other UK nations as well as those working in symptomatic and private sectors. These mammographers should be aware that legislation in other countries may vary from that which applies in England.

2. Risk assessment

The Management of Health and Safety at Work Regulations 1999 states that the employer must risk-assess the workplace and employees must co-operate with the employer so that legal requirements are met.

Risk assessment identifies sensible measures to control risk in the workplace.

You should:

• identify what can harm people in your workplace
• identify who might be harmed and how
• consult employees and seek their views
• evaluate the risks and decide on appropriate controls, taking into account the controls you already have in place
• record your risk assessment
• review and update your assessment annually or when there are workplace changes

Specific areas to cover include the following.

1. Job or task being done: activities, workload, work pacing, shift work and fatigue.
2. Equipment used: its design in terms of size, shape, controls, displays, and how appropriate it is for the task.
3. Information used: how it is presented, accessed and changed.
4. The physical environment: temperature, radiation, humidity, lighting, noise, vibration, fumes.
5. Relevant manual handling training: task, load, working environment and individual capability.
6. Display screen equipment: standard operations, including cleaning and maintenance activities.

Consider:

• fixed or constrained body positions
• continual repetition of movements
• force concentrated on small parts of the body such as the thumb, hand or wrist
• a pace of work that does allow sufficient recovery between movements

Useful Health and Safety Executive (HSE) risk assessment tools include:

• body mapping tool
• preventing musculoskeletal disorders (MSDs) guidance
• risk assessment worksheet
• A brief guide: Ergonomics and human factors at work
• risk assessment leaflet: A brief guide to controlling risk in the workplace
• risk assessment frequently asked questions
• Controlling the risks in the workplace
• employer’s responsibilities

You should also refer to Breast screening: guidance for breast screening mammographers.

3. Ergonomic recommendations: management considerations

The employing trust must make sure accommodation for the service is fit for purpose. It is the breast screening service’s responsibility to make best use of the space by considering equipment required and workflow patterns. This will make sure both the trust and screening management meet their responsibilities to enable safe working practice for staff and to avoid injury.

3.1 Room size and design

When considering room design and layout appropriate trust risk assessments should be completed and fully documented, taking into account all staff working in the area.

A well designed mammography workspace can improve safe working, reduce WRMSK disorders and improve workflow. The working triangle should be minimised but must include handwashing facilities.

Consideration of space for accessory equipment should be factored into the room design. This could include couches (for prone procedures), specimen imaging cabinets, procedure trolley, storage (floor standing and wall mounted) for paddles and stereo equipment, acquisition workstations and other accessories.

Space is an essential consideration in the design and room layout on a mobile screening van. It is advisable that services visit breast screening units to look at mobile van design and learn from colleagues’ experience as to what has worked well and what they would change.

Education and training has a major role in raising mammographers’ awareness and applying safe strategies at work.

Plan should include:

• size: the room must be big enough to accommodate size, height and movement of equipment, accessories such as positioning tools, storage for auxiliary equipment and consumables, workstations and hand washing facilities
• space optimisation: once equipped, the room must be big enough to accommodate core staff, patients and carers, be uncluttered and accessible
• storage: store frequently used equipment at an appropriate level where bending, stretching or twisting is minimised
• access: consider placement of room in relation to other work areas such as reception, PAC’s workstations and door openings or fire exits
• surroundings: ensure adequate lighting, acceptable noise levels, working temperature and humidity
• signs and warning lights: information displayed is accessible to read and can be updated with ease

Further HSE information includes:

• How to sit correctly
• Provide the right workplace facilities
• MSD – manual handling
• Manual handling at work. A Brief Guide
• Work equipment and machinery

3.2 Equipment

Equipment design and choice is an important aspect of good ergonomic planning in any department. When procurement is agreed it is useful to select a team from the service to evaluate the various pieces of equipment.

Appendix 1 contains a suggested template to use when carrying out the evaluation. It can be modified if some questions are not deemed relevant or changed to suit personal needs.

Ideally, the evaluation form should be completed independently by each person in the team and the results collated at the end of the process to give each piece of equipment an overall score.

You should consider:

• the design of the equipment as different manufacturers will vary
• the location of the equipment and whether it is to be in a static or mobile unit as this may impact on the choice of equipment during selection of repurchasing

Good positioning techniques should be taught by the national training centres during recognised training and update courses (academic and clinical).

Mammographers’ positioning practice should be observed regularly by an experienced clinical practitioner (this could act as a CPD activity). The colleague should identify behaviour and practices that may lead to ergonomic injuries and advise on alternative approaches.

Mammographers have a responsibility for their own health and safety and for the safety of others and must maintain good and safe working practices.

3.3 Appointments

In general, mammography screening appointments should not be less than 6 minutes long. This can depend on uptake.

When using SMART clinics, booking coordinators must ensure even distribution of appointments throughout the working day. This helps to offset the unpredictability of client attendance and thereby reduce WRMSK disorders.

This can be achieved by:

• distributing second timed appointments throughout the day
• randomising batches where possible
• selecting double slots for special appointments
• spacing out the booking of re-book slots
• ensuring the total target for the day is set in accordance with uptake levels and is realistic

There must be regular rest breaks throughout the day in accordance with national guidance. In addition, there should be small breaks to allow for recovery time between screening clients, for example by regularly alternating taking mammograms with reception duties.

3.4 Staff rotation and working patterns

To reduce the risk of WRMSK disorders, you should consider rotating staff between screening and assessment clinics and other duties to avoid working consecutive days in screening.

4. Ergonomic recommendations – clinical considerations

It is important for the employing trust and the individual employee to consider important recommendations in mammography clinical practice to promote safe working practices and minimise the risk of injury.

4.1 Body areas at risk when undertaking mammography

Areas prone to work-related injury in screening mammography include:

• base of thumb
• hand and wrist
• neck
• shoulders
• elbows
• lower spine
• knees

Risk factors include:

• stretching and twisting
• force
• frequent repeated movements
• poor posture
• the relative height of the client/practitioner
• time pressures, including clinic workload and appointment scheduling
• client body size and mobility
• client anxiety
• mammographer mobility and fitness

Important considerations include:

• adoption of best ergonomic clinical practice by practitioners
• good health of workforce to promote longevity of service
• room design
• equipment design

4.2 Positioning

It is important to identify alternative postures for mammography practitioners while performing mammography, which can help to reduce the risk of WRMSK disorders.

Mammography practitioners also need to make sure that clear instructions are given to the client for ease of positioning and to help reduce the mammographer’s discomfort and potential for injury.

From an occupational health perspective, prevention is more effective than treatment for WRMSK disorders.

Employ common sense where very tall or very short clients are to be screened and consider the use of a positioning aid.

Where practical, mammographers should be encouraged to ask a colleague for help when needed.

It is important to adapt techniques to suit the client body habitus of each individual client.

It is recommended that mammographers use a suitable stool for positioning.

Where women attend in wheelchairs, 2 mammographers must always be present.

Observing colleagues and offering feedback to correct poor technique and poor adoption of posture is valuable and should be seen as good practice.

4.3 Good practice with positioning

Good communication with the client will enable them to move independently rather than be moved by the mammographer.

Use the whole hand, or as much of the hand as possible, to position the breast, rather than relying on the thumb and forefinger (see image below).

Avoid unnecessary use of manual hand compression controls to prevent wrist strain.

Mammographers should make sure they are familiar with the location of x-ray unit controls so they do not overstretch unnecessarily.

Figure 1: source National Breast Screening Training Centre, King’s College Hospital

Try not to use the same fingers to press the exposure button. Different exposure control designs exist, involving different types of movement (see below). Selecting an appropriate means of control can avoid injury.

Figure 2: source Anne Teape, BreastCheck

Figure 3: source Anne Teape, BreastCheck

Before positioning a woman, make sure the foot pedals are placed correctly so there is no need to stretch extremities.

Figure 4: source National Breast Screening Training Centre, Kings College Hospital

Consider the seated position for screening, both for client and mammographer. This will need suitable aids and flooring. Each mammographer must adjust their seat height and proximity to suit each client, and each should avoid over-extension of their elbows and shoulders. The wheels on the stool must be selected to give the right level of grip for the type of floor.

Figure 5: source National Breast Screening Training Centre, Kings College Hospital

Try not to use the same fingers to press the exposure button. Different exposure control designs exist, involving different types of movement. Selecting an appropriate means of control can avoid injury.

Figures 6 and 7: source National Breast Screening Training Centre, Kings College Hospital

Store additional equipment at waist height to reduce bending and stretching.

Where possible, set the height of the modality acquisition workstation. Some manufacturers have introduced touchscreen technology to reduce the use of keyboards.

Always have 2 practitioners available where clients with additional needs are to be screened.

Mammographers should alternate their starting position between clients from seated to standing to reduce repetition where possible.

4.4 Exercises

To reduce WMSK, HSE recommends that employees complete exercises before the start of the working day and during their micro-breaks between screening examinations.

Employees may want to seek guidance from occupational health colleagues.