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Work 51 (2015) 401–409 DOI 10.3233/WOR-141939 IOS Press
Hospital nurses tasks and work-related musculoskeletal disorders symptoms: A detailed analysis Florentino Serranheiraa,b,c,∗, Mafalda Sousa-Uvaa and António Sousa-Uvaa,b,c a
Escola Nacional de Saúde Pública, Universidade Nova de Lisboa, Lisbon, Portugal Centro de Malária e Doenças Tropicais – Saúde Pública, Lisbon, Portugal c Centro de Investigação em Saúde Pública, Escola Nacional de Saúde Pública, Universidade Nova de Lisboa, Lisbon, Portugal b
Received 18 May 2013 Accepted 14 February 2014
Abstract. BACKGROUND: Hospital work-related musculoskeletal disorders (WRMSDs) symptoms are highly prevalent and nurses are considered the health care professional group more often affected by WRMSDs. OBJECTIVES: Understanding the effects of nursing tasks on WRMSDs symptoms. METHODS: Portuguese nurses answered to a modified Nordic Musculoskeletal symptoms Questionnaire. The increased likelihood of having WRMSDs symptoms was estimated from a daily working task schedule and the probability of suffering from lumbar WRMSDs symptoms intensity was also estimated. RESULTS: Hospital nurses studied (n = 1.396) were mainly females (75.8%), and most of them reported more than 1 symptom (88%). Low-back pain was the most prevalent complaint (60.9%). Tasks performed more than 10 times a day, such as invasive procedures (OR = 2.142); care of hygiene and patient comfort in bed (OR = 2.484); patient mobilization in bed (OR = 2.022); and patient feeding (OR = 2.186) had an effect on dorsal and lumbar symptoms (p < 0.05). Those tasks involving invasive procedures were just the only ones producing symptoms simultaneously on every studied body part, such as lumbar, dorsal, wrist/hand and ankles/feet areas. CONCLUSIONS: Tasks with a greater effect on low-back pain intensity were patient bed feeding and patient hygiene and care. We found, when analysing simultaneously the effects of every task on the likelihood of having low-back symptoms, that involving invasive procedures were that only ones affecting simultaneously the presence of almost all WRMSDs symptoms studied. Keywords: Nursing, musculoskeletal symptoms, low-back pain, patient lifting, occupational health
1. Introduction Work-related musculoskeletal disorders (WRMSDs) are a major occupational issue in the relationships between work and disease, namely in nursing staff [1–3]. ∗ Corresponding author: Florentino Serranheira, Departamento de Saúde Ocupacional e Ambiental (DSOA), Escola Nacional de Saúde Pública, Universidade Nova de Lisboa, Avenida Padre Cruz, 1600-560 Lisboa, Portugal. Tel. +351217512100; E-mail: [email protected].
The aetiology of such disorders is multifactorial [4,5] and many studies conducted in nurses have found associations between work-related musculoskeletal symptoms and: i) poor posture (including awkward and static postures) [6]; ii) lifting patients and other manual handling tasks; iii) transferring patients out of bed [7, 8]; iv) work-related stress [9]; v) organizational factors, like nursing staff cuts [10]; vi) and also some individual factors [11]. As a matter of fact, in recent years psychosocial factors, including time pressure, are getting greater importance as occupational hazards.
c 2015 – IOS Press and the authors. All rights reserved 1051-9815/15/$35.00
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In occupational medicine it is generally assumed that muscular discomfort and/or pain may be an early sign of musculoskeletal disorders [12] and Ergonomics use this aspect in WRMSDs risk assessment. Studies reporting work-related short-term musculoskeletal discomfort confirm that this is a sign and even a predictor of long-term musculoskeletal pain as well as WRMSDs [13]. Many studies have focused particularly in the association between nursing demands and occupational hazards, and reported pain on the back, neck and shoulder among healthcare workers [14–16]. Nursing often requires heavy physical work tasks such as lifting and transferring patients, which require sudden movements, most of the time against non-neutral postures, working in awkward postures, and operating hazardous equipment [17]. Nurses workrelated musculoskeletal symptoms varies depending on the wards, the hospitals and even the countries they are originated from [1,17–20], which appear to be related with many different nursing occupational exposures to WRMSDs hazards. For instance, patient transfers have different physical demands in different context but requires always trunk mobilization in sudden postures. Fewer studies have examined the association of nurse’s working tasks and the frequency in which are performed with WRMSDs symptoms [17]. Therefore in the present study we aimed for investigating the effects of some nursing work tasks on perceived musculoskeletal symptoms. We also analysed if the intensity of the most prevalent WRMSDs symptoms (in the low-back) were affected by nurses’ working tasks frequency.
2. Methods Portuguese nurses were invited to participate in a self-reported musculoskeletal symptoms study through a questionnaire that was used as a survey instrument. The request was made at the Portuguese Nursing Council (PNC) website and it was available online on the Survey Monkey Platform between June 2010 and February 2011. Respondents for the study were nurses registered in the PNC. The questionnaire collected data in four sections: (i) demographic profile such as age, gender weight and height; (ii) the presence or absence of musculoskeletal symptoms in nine anatomical sites in the past 12 months and in the past 7 days; (iii) details on the respondent’s job and reported relation with symptoms,
such as information about work status, work setting, years of practice and nursing activities and (iv) general health status. The questionnaire has been adapted from the Nordic Questionnaire on Musculoskeletal disorders (NMQ – Nordic Musculoskeletal Questionnaire), previously validated and accepted as a survey instrument [21,22] and already used in Portugal [19,23,24]. The analysed body segments were the trunk (cervical, dorsal and low back), the upper limbs (shoulders, elbows and wrist/hand) and the lower limbs (thighs, knees and ankles/feet). Statistical analysis was performed using the software Statistical Package for Social Sciences (SPSS) version PASW Statistics 21. The increased likelihood of having WRMSDs symptoms in the past 12 months was estimated using the Logistic Regression Model. The probability of having an increased level of intensity of lumbar WRMSDs symptoms was estimated from working tasks that had an effect greater than 2 (Odds Ratio > 2) on the presence of such symptoms. For that purpose it was used the Multinomial Regression Model. A level of significance of 5% was set for all statistical tests. 3. Results The questionnaire was answered by 1.396 hospital nurses, accordingly to the Portuguese Nursing Council (2010), representing up to 5.2% of all nationwide hospital nurses (n = 26.920). This sample was quite largely female (75.8%), having averages figures for age (37.2 years); weight (67.02 kg), and height (1.65 m) (Table 1). Among the 1.396 hospital nurses, 69.6% referred to work night-shifts, and 88% reported to have more than 1 musculoskeletal symptom. Low back musculoskeletal symptoms were quoted as the most prevalent in either the last 12 months or the last 7 days (60.9% and 48.8%, respectively) (Fig. 1). Upper back symptoms were also referred in a large majority of nurses (48.5%). Upper and lower limbs symptoms were referred as less frequent complaints. The intensity levels of reported WRMSDs symptoms in the last 12 months are shown in Fig. 2. These results revealed to be different from those about the presence of musculoskeletal symptoms since symptoms intensity were at a higher level greater (intense or very intense) not only for the low back pain (45.8%) but also for elbows (43.1%), and shoulders (38.6%). This may be related with heavier task demands.
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Table 1 Descriptive information of respondents Age (years) Weight (Kg) Height (cm) Weekly working hours Nursing experience: years
Back
40%
50%
60%
45.79%
Shoulders Elbows
12 months
Minimum 23 42 56 8 0,8 20%
Maximum 69 128 193 100 44
40%
60%
Shoulders 60.85% 48.80%
34.5% 68.9% 31.1% 54.2% 45.8% 61.4% 38.6%
Light/Moderate
43.1% 69.1% 30.9%
36.27%
Hip/Thighs
67.6% 32.4%
18.10%
Knees
69.0% 31.0%
7.49%
Ankle/Feets
68.1% 31.9%
4.00% 29.74%
Fig. 2. Symptoms intensity by body segment in the last 12 months.
12.00%
0%
20%
40%
6.50%
79.8% 20.2% 38.6%
7 days
10.10%
61.4% 41.5%
blood pressure monitoring and glucose finger prick tesng nurse homecare
58.5% 95.9% 4.1% 74.7%
care of hygiene and comfort of paents in bed
24.83%
12 months
46.4% 53.6%
paents mobilizaon in bed
Fig. 1. Prevalence of work-related musculoskeletal symptoms in different body segments.
Analyses of the working tasks frequency per day rates allowed us to conclude that the most frequent nursing tasks were (more than 6 times a day): drugs administration (61.4%), blood pressure monitoring, blood glucose finger prick testing (58.5%), and positioning and mobilization of patients in bed (53.6%) (Fig. 3). Homecare nursing (95.9%) and mechanical support patient lifting (94.6%) were the tasks done less than 5 times a day by nurses. Logistic regression allowed observing tasks with statistically significant effect on the likelihood of having WRMSDs symptoms, when performed 2 to 5, 6 to 10, and more than 10 times a day relatively to 0 to 1 time a day. Results for back, upper limbs and lower limbs are shown in Tables 2, 3 and 4 respectively.
70.2%
paent liing without mechanical assistance
29.8% 94.6% 5.4% 76.2%
paents feeding care of hygiene and comfort of paents in WC
>6 70.4%
29.6%
16.80% paents liing with mechanical assistance
≤5
25.3%
paents transfers
7 days
100%
68.1%
drugs administraon
21.75%
80%
31.9%
wound treatment
12 months
60%
54.4% 45.6%
informac work
10.51%
invasive procedures
7 days
Intense/very intense
56.9%
Elbows Wrist/Hands
80% 65.5%
Lumbar
22.10%
7 days
7 days
0% Cervical Dorsal
7 days
12 months
Standard deviation 9.16 13.46 11.04 8.9 8.9
70%
26.50%
12 months
7 days
Median 36 65 165 40 13
48.50%
7 days
Wrist/hands
Limbs
30%
12 months
12 months
Knees
Upper
20%
7 days
12 months
Ankle/feet
Lower Limbs
10%
12 months
Hip/Thighs
Lumbar
Dorsal
Cervical
0%
Average 37.20 67.02 165.4 41.14 13.25
23.8% 89.3% 10.7%
Fig. 3. Daily frequency ( 5 and > 6) of nurses’ working tasks.
It was observed that nurses’ working tasks had no effect on the presence of cervical symptoms (Table 2). However the frequency of some tasks had an effect on the presence of dorsal and lumbar symptoms, being those that had a greater effect. For instance it was observed a clear effect particularly in those tasks performed more than 10 times a day, such as invasive procedures (OR = 2.149), drugs administration (OR = 1.857), blood pressure monitoring and blood glucose finger prick testing (OR = 1.595), care of hygiene and comfort of patient in bed (OR = 2.484), patients mobilization in bed (OR = 2.022), patient transfers (OR = 1.751), patient lifting
2 to 5 times per day 6 to 10 times per day More than 10 times per day 2 to 5 times per day 6 to 10 times per day More than 10 times per day 2 to 5 times per day 6 to 10 times per day More than 10 times per day 2 to 5 times per day 6 to 10 times per day More than 10 times per day 2 to 5 times per day 6 to 10 times per day More than 10 times per day 2 to 5 times per day 6 to 10 times per day More than 10 times per day 2 to 5 times per day 6 to 10 times per day More than 10 times per day 2 to 5 times per day 6 to 10 times per day More than 10 times per day 2 to 5 times per day 6 to 10 times per day More than 10 times per day
2 to 5 times per day 6 to 10 times per day More than 10 times per day 2 to 5 times per day 6 to 10 times per day More than 10 times per day 2 to 5 times per day 6 to 10 times per day More than 10 times per day
Reference category: 0 to 1 time per day.
Patients mobilization in bed
Drugs Administration
Invasive procedures
Categories
Reference category: 0 to 1 time per day.
Care of Hygiene and comfort of patients in WC
Patients feeding
Patient lifting without mechanical assistance
Patient transfers
Patients mobilization in bed
Care of Hygiene and comfort of patients in bed
Blood pressure monitoring and glucose finger prick testing
Drugs administration
Invasive procedures
Categories
0.895
0.737
0.867
0.557
0.169
0.310
0.610
0.769
p value 0.319
Dorsal Odds ratio (CI95%) ... ... ... ... 1.909 (1.242–2.932) ... ... ... ... ... ... 1.787 (1.067–2.991) ... ... 1.691 (1.152–2.481) ... ... ... ... 1.603 (1.111–2.313) 2.129 (1.396–3.343) ... ... 1.653 (1.022–2.674) ... 1.669 (1.011–2.737) ...
Back
Shoulders Odds ratio (CI95%) ... ... ... ... ... ... ... ... ... 0.195
0.244
p value 0.194
Elbows Odds ratio (CI95%) ... ... ... ... ... ... ... ... ...
Upper limbs
Table 3 Tasks effects on upper limb symptoms in hospital nurses
Cervical Odds ratio (CI95%) ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ...
Table 2 Tasks effects on back musculoskeletal symptoms in hospital nurses
0.526
0.761
p value 0.384
0.126 0.012 0.001 0.246 0.224 0.041 0.335 0.045 0.072
0.508 0.107 0.027 0.238 0.073 0.007 0.058
0.360 0.003 0.083 0.444
p value 0.189
Wrist/hand Odds ratio (CI95%) 1.430 (1.017–2.012) 1.632 (1.078–2.470) 1.724 (1.134–2.619) ... ... 1.677 (1.079–2.608) ... ... 1.555 (1.024–2.361)
Lumbar Odds ratio (CI95%) ... ... 2.149 (1.432–3.225) ... 1.682 (1.095–2.584) 1.857 (1.264–2.728) ... ... 1.595 (1.094–2.326) 1.363 (1.020–1.820) 1.629 (1.121–2.368) 2.484 (1.395–4.424) ... ... 2.022 (1.354–3.019) ... ... 1.751 (1.102–2.782) ... ... 1.709 (1.066–2.739) 1.355 (1.014–1811 ... 2.186 (1.283–3.725) ... 1.779 (1.039–3.048) ...
p value 0.040 0.021 0.011 0.286 0.070 0.022 0.294 0.721 0.038
p value 0.080 0.193 0.001 0.188 0.017 0.020 0.614 0.146 0.015 0.037 0.011 0.002 0.520 0.290 0.001 0.535 0.119 0.018 0.124 0.064 0.026 0.040 0.318 0.004 0.137 0.036 0.400
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Low
Very high
High
Moderate
0 to 1 time per day 2 to 5 times per day 6 to 10 times per day 0 to 1 time per day 2 to 5 times per day 6 to 10 times per day 0 to 1 time per day 2 to 5 times per day 6 to 10 times per day More than 10 times per day
0.333
p value 0.468
Knees Odds ratio (CI95%) ... ... ... ... ... ...
Lower limbs
0.663
p value 0.696
0.111 (0.023–0.544) 0.071 (0.015–0.344) 0.156 (0.029–0.847)
p > 0.05
p value 0.018 0.012 0.003 0.371 0.001 0.152
p > 0.05 0.048 p > 0.05
p > 0.05
Hygiene and care of patients in bed Odds ratio (CI95%) p value p > 0.05
Ankles/feet Odds ratio (CI95%) 1.563 (1.080–2.264) 1.762 (1.130–2.748) 1.943 (1.244–3.034) ... 2.11 (1.391–3.202) ...
0.027 p > 0.05 p > 0.05 0.007 0.001 0.284 (0.082–0.988) 0.031 Reference Categories
Patients feeding Odds ratio (CI95%) p value p > 0.05
0.180 (0.040–0.821)
Invasive procedures
p > 0.05
p value p > 0.05
Table 5 Effects of tasks frequency on nurses’ symptoms intensity
Thighs Odds ratio (CI95%) ... ... ... ... ... ...
Intensity Odds ratio (CI95%)
2 to 5 times per day 6 to 10 times per day More than 10 times per day 2 to 5 times per day 6 to 10 times per day More than 10 times per day
Reference category: 0–1 time per day.
Wound treatment
Invasive procedures
Categories
Table 4 Tasks effects on lower limb symptoms in hospital nurses
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without mechanical equipment (OR = 1.709), and patient feeding (OR = 2.186). All these findings suggest that nursing tasks could be determinant factors for musculoskeletal symptoms and that the frequency in which they are performed is a major contributor for spine symptoms, particularly in the upper back (dorsal) and the lower back (lumbar) areas (Table 2). It was also possible observing that the analysed working tasks frequency have no significant effect on the likelihood of having shoulder or elbow symptoms (Table 3). However the frequency had significant effects on hands symptoms at invasive procedures, drug administration, or positioning and mobilization of patients in bed. Within those tasks with effect on wrist and hands symptoms, the one with a stronger effect was the invasive procedures (2 to 5 times per day: OR = 1.430; 6 to10 times per day: OR = 1.632 and more than10 times per day: OR = 1.724). Results from the lower limbs symptoms revealed that there is no effect of working tasks on the likelihood of having thighs or knees symptoms (Table 4). But these findings also revealed that the frequency in which invasive procedures, and wound treatment have an impact on the presence of ankles/feet symptoms. Invasive procedures had an effect when performed above 2 times a day (2 to 5 times per day: OR = 1.563; 6 to 10 times per day: OR = 1.762 and more than 10 times per day: OR = 1.943). Wound treatment had a greater effect on the same symptoms but only at a frequency of 6 to 10 times per day (OR = 2.110). After the identification of those musculoskeletal symptoms being most affected by nursing working tasks frequency (low back symptoms), we made a more detailed analysis determining the task impact on lumbar symptoms intensity. For that purpose there were analysed only the tasks that increasing the probability of having low back symptoms with an Odds Ratio equal or above 2 (Table 5). Results revealed that “patients feeding” when performed only 0 to 1 time a day relatively to more than 10 times a day decreases 82% the likelihood of having a high intensity of low-back symptoms; and decreases in 92.9% the likelihood of having a very high intensity of low-back symptoms. The patients feeding performed 2 to 5 times a day in comparison to 10 times a day decreases the probability of having very higher symptoms in 88.9%; and 6 to 10 times a day versus 10 times a day in 84.4%. The patient hygiene and comfort in bed when performed 2 to 5 times a day against more than 10 times
a day decreases the probability of having very high intensity of low-back symptoms in 71.6%. All these results reveal that nursing tasks frequency is a very important risk factor of WRMSDs, mainly those ones involving bed care. Because in a working day nurses are exposed simultaneously to almost all of the studied tasks, we also decided to test by logistic regression what is the task with greater effect on the likelihood of having low back symptoms, but in the presence of each one of the other tasks. Results revealed that invasive procedures were the most important task for the presence of such symptoms (OR = 3.264).
4. Discussion Musculoskeletal symptoms can be initiated by either muscular tension or muscle fatigue producing very often discomfort, pain and sometimes musculoskeletal disorders [25]. Identifying those musculoskeletal symptoms and their related occupational risk factors need to be addressed for the elaboration of a standard baseline allowing us to compare differences and tendencies as predictors/indicators for WRMSDs worsening, also being able to give us information on prevention of these conditions. Results showed, similarly to previous studies [14, 17–19,26,27], a high frequency of musculoskeletal symptoms in the last 12 months (cervical = 48.5%; dorsal = 45.9%; lumbar = 60.9%; shoulder = 36.2%; elbows = 7.4%; wrist/hands = 29.7%; hips/thighs = 19.5%; knees = 21.7%; ankles/feet = 24.8%). The nurses’ prevalence of self-reported musculoskeletal symptoms for the previous 12 months and for the previous 7 days, were similar with other studies [6, 17,18,26]. Low back symptoms were the most frequent and worst intensity-wise self-reported symptoms. These findings were also similar to results published in previous studies, where low back pain was described as a very frequent occupational problem in nurses, with frequencies ranging between 40% and 60% [1,17,18, 31–33]. In this study, results from binary logistic regression showed that working tasks had no effect on the increased likelihood of having shoulders, elbows, cervical, thighs and knees musculoskeletal symptoms. These results suggested that the working tasks analysed in this study seemed not to play an important role for the presence of those symptoms, perhaps being
F. Serranheira et al. / Hospital nurses tasks and work-related musculoskeletal disorders symptoms
much more influenced by other work occupational hazards, like work-related stressors, organizational factors and some individual factors, such as age, gender or BMI (body mass index) [9–11]. Nevertheless, there were tasks increasing the probability of having WRMSDs symptoms in upper back, low back, wrist/hands and in ankles/feet areas. These effects were more evident when those tasks were performed more than 10 times a day, highlighting the importance of these task frequencies. Those musculoskeletal symptoms where the tasks had a bigger influence were low back and upper back symptoms, and in a lesser way the wrist/hand and ankles/feet areas. Results suggested that those musculoskeletal symptoms in upper back, low back, wrist/hand and in ankles/feet body regions, were more associated to specific nursing working tasks, which probably means that they could be prevented with adequate risk management measures. Neck symptoms are also described as frequent WRMSDs’ symptoms in nurses [34], and it was confirmed it in this study. However, it was not identified any significant effect of working tasks on these symptoms. As a matter of fact, it was considered that further research must be developed in order to identify other possible risk factors, or results of confounding factors didn’t allow identifying any effects. Maybe some occupational-type confounders could explain those results such as the professional category, the predominance of direct contact with patients and other physical work demands not analysed. Invasive procedures were just the specific/only working task producing simultaneously effects on all lumbar, dorsal, wrist/hand and ankles/feet musculoskeletal symptoms. This may be explained by the inner characteristics of those procedures where demands from all body segments were required and, on the other hand, because it may involve some stressors exposure. Because low-back pain was the most prevalent symptom, we decided to make a deeper analysis in order to investigate the impact of working tasks (with effect on these symptoms greater than 2 (OR > 2)) on the likelihood of having increased levels of lumbar symptoms intensity. Tasks with an odds ratio greater than 2 (when performed more than 10 times per day) were: patient hygiene and care in bed (OR = 2.484); feeding (OR = 2.186); and invasive procedures (OR = 2.149). There were interesting results, since the invasive procedures were the only analysed job risk factor with no influence on the levels of low back symptoms in-
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tensity, and patient feeding was the task with a greater effect on the worsening of such symptoms particularly when it occurred more often. Another conclusion was that patient feeding when performed only 0 to 1 time a day, compared to more than 10 times a day, decreases in 92.9% the likelihood of having very high levels of low back symptoms intensity. These results for invasive procedures may be related with the importance of this task as a stressor and also may be related with some adopted working postures. Since hospital nurses are exposed in a daily basis to a large variety of tasks simultaneously, we analysed the task with greater effect on the probability of having low-back symptoms, taking into account the other tasks effects. In this more realistic work scenario we observed that invasive procedures were the most important task for the presence of such symptoms (OR = 3.264). Concerning possible limitations, non-probability samples don’t allow a generalization of results, constituting a limitation to the external validity of this study. Regarding the internal validity, there could be a selection bias, since nurses with symptoms are more prone to answer these kinds of surveys. There could also be an information bias because our respondents might have been giving exaggerated answers if the problems in study are seen as a difficulty to their professions. Another important issue is the relationship between musculoskeletal distress or symptoms and WRMSDs. In fact, this study only demonstrated associations and not a causal relationship. Only a prospective cohort may produce more research evidence on this issue.
5. Conclusions In the present study, nursing work tasks revealed to be a very important occupational hazard for the presence of lumbar, dorsal, wrist/hand and ankles/feet musculoskeletal symptoms, being invasive procedures the only working tasks having simultaneously effects in all of these symptoms. Lower back symptoms were the most frequent selfreported WRMSDs’ symptoms and those felt with higher intensity. Tasks with a greater effect on lowback pain intensity were patient feeding and patient hygiene and care in bed. When testing simultaneously the effects of every task in the likelihood of having lower back musculoskeletal symptoms, invasive procedures were the only ones affecting the occurrence of such symptoms.
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These results for invasive procedures may be related with some adopted working postures and also with some occupational stressors exposure.
[14]
[15]
Acknowledgements [16]
We would like to thank the Ordem dos Enfermeiros and all the nurses who participated in the survey. [17]
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Work 51 (2015) 401–409 DOI 10.3233/WOR-141939 IOS Press
Hospital nurses tasks and work-related musculoskeletal disorders symptoms: A detailed analysis Florentino Serranheiraa,b,c,∗, Mafalda Sousa-Uvaa and António Sousa-Uvaa,b,c a
Escola Nacional de Saúde Pública, Universidade Nova de Lisboa, Lisbon, Portugal Centro de Malária e Doenças Tropicais – Saúde Pública, Lisbon, Portugal c Centro de Investigação em Saúde Pública, Escola Nacional de Saúde Pública, Universidade Nova de Lisboa, Lisbon, Portugal b
Received 18 May 2013 Accepted 14 February 2014
Abstract. BACKGROUND: Hospital work-related musculoskeletal disorders (WRMSDs) symptoms are highly prevalent and nurses are considered the health care professional group more often affected by WRMSDs. OBJECTIVES: Understanding the effects of nursing tasks on WRMSDs symptoms. METHODS: Portuguese nurses answered to a modified Nordic Musculoskeletal symptoms Questionnaire. The increased likelihood of having WRMSDs symptoms was estimated from a daily working task schedule and the probability of suffering from lumbar WRMSDs symptoms intensity was also estimated. RESULTS: Hospital nurses studied (n = 1.396) were mainly females (75.8%), and most of them reported more than 1 symptom (88%). Low-back pain was the most prevalent complaint (60.9%). Tasks performed more than 10 times a day, such as invasive procedures (OR = 2.142); care of hygiene and patient comfort in bed (OR = 2.484); patient mobilization in bed (OR = 2.022); and patient feeding (OR = 2.186) had an effect on dorsal and lumbar symptoms (p < 0.05). Those tasks involving invasive procedures were just the only ones producing symptoms simultaneously on every studied body part, such as lumbar, dorsal, wrist/hand and ankles/feet areas. CONCLUSIONS: Tasks with a greater effect on low-back pain intensity were patient bed feeding and patient hygiene and care. We found, when analysing simultaneously the effects of every task on the likelihood of having low-back symptoms, that involving invasive procedures were that only ones affecting simultaneously the presence of almost all WRMSDs symptoms studied. Keywords: Nursing, musculoskeletal symptoms, low-back pain, patient lifting, occupational health
1. Introduction Work-related musculoskeletal disorders (WRMSDs) are a major occupational issue in the relationships between work and disease, namely in nursing staff [1–3]. ∗ Corresponding author: Florentino Serranheira, Departamento de Saúde Ocupacional e Ambiental (DSOA), Escola Nacional de Saúde Pública, Universidade Nova de Lisboa, Avenida Padre Cruz, 1600-560 Lisboa, Portugal. Tel. +351217512100; E-mail: [email protected].
The aetiology of such disorders is multifactorial [4,5] and many studies conducted in nurses have found associations between work-related musculoskeletal symptoms and: i) poor posture (including awkward and static postures) [6]; ii) lifting patients and other manual handling tasks; iii) transferring patients out of bed [7, 8]; iv) work-related stress [9]; v) organizational factors, like nursing staff cuts [10]; vi) and also some individual factors [11]. As a matter of fact, in recent years psychosocial factors, including time pressure, are getting greater importance as occupational hazards.
c 2015 – IOS Press and the authors. All rights reserved 1051-9815/15/$35.00
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In occupational medicine it is generally assumed that muscular discomfort and/or pain may be an early sign of musculoskeletal disorders [12] and Ergonomics use this aspect in WRMSDs risk assessment. Studies reporting work-related short-term musculoskeletal discomfort confirm that this is a sign and even a predictor of long-term musculoskeletal pain as well as WRMSDs [13]. Many studies have focused particularly in the association between nursing demands and occupational hazards, and reported pain on the back, neck and shoulder among healthcare workers [14–16]. Nursing often requires heavy physical work tasks such as lifting and transferring patients, which require sudden movements, most of the time against non-neutral postures, working in awkward postures, and operating hazardous equipment [17]. Nurses workrelated musculoskeletal symptoms varies depending on the wards, the hospitals and even the countries they are originated from [1,17–20], which appear to be related with many different nursing occupational exposures to WRMSDs hazards. For instance, patient transfers have different physical demands in different context but requires always trunk mobilization in sudden postures. Fewer studies have examined the association of nurse’s working tasks and the frequency in which are performed with WRMSDs symptoms [17]. Therefore in the present study we aimed for investigating the effects of some nursing work tasks on perceived musculoskeletal symptoms. We also analysed if the intensity of the most prevalent WRMSDs symptoms (in the low-back) were affected by nurses’ working tasks frequency.
2. Methods Portuguese nurses were invited to participate in a self-reported musculoskeletal symptoms study through a questionnaire that was used as a survey instrument. The request was made at the Portuguese Nursing Council (PNC) website and it was available online on the Survey Monkey Platform between June 2010 and February 2011. Respondents for the study were nurses registered in the PNC. The questionnaire collected data in four sections: (i) demographic profile such as age, gender weight and height; (ii) the presence or absence of musculoskeletal symptoms in nine anatomical sites in the past 12 months and in the past 7 days; (iii) details on the respondent’s job and reported relation with symptoms,
such as information about work status, work setting, years of practice and nursing activities and (iv) general health status. The questionnaire has been adapted from the Nordic Questionnaire on Musculoskeletal disorders (NMQ – Nordic Musculoskeletal Questionnaire), previously validated and accepted as a survey instrument [21,22] and already used in Portugal [19,23,24]. The analysed body segments were the trunk (cervical, dorsal and low back), the upper limbs (shoulders, elbows and wrist/hand) and the lower limbs (thighs, knees and ankles/feet). Statistical analysis was performed using the software Statistical Package for Social Sciences (SPSS) version PASW Statistics 21. The increased likelihood of having WRMSDs symptoms in the past 12 months was estimated using the Logistic Regression Model. The probability of having an increased level of intensity of lumbar WRMSDs symptoms was estimated from working tasks that had an effect greater than 2 (Odds Ratio > 2) on the presence of such symptoms. For that purpose it was used the Multinomial Regression Model. A level of significance of 5% was set for all statistical tests. 3. Results The questionnaire was answered by 1.396 hospital nurses, accordingly to the Portuguese Nursing Council (2010), representing up to 5.2% of all nationwide hospital nurses (n = 26.920). This sample was quite largely female (75.8%), having averages figures for age (37.2 years); weight (67.02 kg), and height (1.65 m) (Table 1). Among the 1.396 hospital nurses, 69.6% referred to work night-shifts, and 88% reported to have more than 1 musculoskeletal symptom. Low back musculoskeletal symptoms were quoted as the most prevalent in either the last 12 months or the last 7 days (60.9% and 48.8%, respectively) (Fig. 1). Upper back symptoms were also referred in a large majority of nurses (48.5%). Upper and lower limbs symptoms were referred as less frequent complaints. The intensity levels of reported WRMSDs symptoms in the last 12 months are shown in Fig. 2. These results revealed to be different from those about the presence of musculoskeletal symptoms since symptoms intensity were at a higher level greater (intense or very intense) not only for the low back pain (45.8%) but also for elbows (43.1%), and shoulders (38.6%). This may be related with heavier task demands.
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Table 1 Descriptive information of respondents Age (years) Weight (Kg) Height (cm) Weekly working hours Nursing experience: years
Back
40%
50%
60%
45.79%
Shoulders Elbows
12 months
Minimum 23 42 56 8 0,8 20%
Maximum 69 128 193 100 44
40%
60%
Shoulders 60.85% 48.80%
34.5% 68.9% 31.1% 54.2% 45.8% 61.4% 38.6%
Light/Moderate
43.1% 69.1% 30.9%
36.27%
Hip/Thighs
67.6% 32.4%
18.10%
Knees
69.0% 31.0%
7.49%
Ankle/Feets
68.1% 31.9%
4.00% 29.74%
Fig. 2. Symptoms intensity by body segment in the last 12 months.
12.00%
0%
20%
40%
6.50%
79.8% 20.2% 38.6%
7 days
10.10%
61.4% 41.5%
blood pressure monitoring and glucose finger prick tesng nurse homecare
58.5% 95.9% 4.1% 74.7%
care of hygiene and comfort of paents in bed
24.83%
12 months
46.4% 53.6%
paents mobilizaon in bed
Fig. 1. Prevalence of work-related musculoskeletal symptoms in different body segments.
Analyses of the working tasks frequency per day rates allowed us to conclude that the most frequent nursing tasks were (more than 6 times a day): drugs administration (61.4%), blood pressure monitoring, blood glucose finger prick testing (58.5%), and positioning and mobilization of patients in bed (53.6%) (Fig. 3). Homecare nursing (95.9%) and mechanical support patient lifting (94.6%) were the tasks done less than 5 times a day by nurses. Logistic regression allowed observing tasks with statistically significant effect on the likelihood of having WRMSDs symptoms, when performed 2 to 5, 6 to 10, and more than 10 times a day relatively to 0 to 1 time a day. Results for back, upper limbs and lower limbs are shown in Tables 2, 3 and 4 respectively.
70.2%
paent liing without mechanical assistance
29.8% 94.6% 5.4% 76.2%
paents feeding care of hygiene and comfort of paents in WC
>6 70.4%
29.6%
16.80% paents liing with mechanical assistance
≤5
25.3%
paents transfers
7 days
100%
68.1%
drugs administraon
21.75%
80%
31.9%
wound treatment
12 months
60%
54.4% 45.6%
informac work
10.51%
invasive procedures
7 days
Intense/very intense
56.9%
Elbows Wrist/Hands
80% 65.5%
Lumbar
22.10%
7 days
7 days
0% Cervical Dorsal
7 days
12 months
Standard deviation 9.16 13.46 11.04 8.9 8.9
70%
26.50%
12 months
7 days
Median 36 65 165 40 13
48.50%
7 days
Wrist/hands
Limbs
30%
12 months
12 months
Knees
Upper
20%
7 days
12 months
Ankle/feet
Lower Limbs
10%
12 months
Hip/Thighs
Lumbar
Dorsal
Cervical
0%
Average 37.20 67.02 165.4 41.14 13.25
23.8% 89.3% 10.7%
Fig. 3. Daily frequency ( 5 and > 6) of nurses’ working tasks.
It was observed that nurses’ working tasks had no effect on the presence of cervical symptoms (Table 2). However the frequency of some tasks had an effect on the presence of dorsal and lumbar symptoms, being those that had a greater effect. For instance it was observed a clear effect particularly in those tasks performed more than 10 times a day, such as invasive procedures (OR = 2.149), drugs administration (OR = 1.857), blood pressure monitoring and blood glucose finger prick testing (OR = 1.595), care of hygiene and comfort of patient in bed (OR = 2.484), patients mobilization in bed (OR = 2.022), patient transfers (OR = 1.751), patient lifting
2 to 5 times per day 6 to 10 times per day More than 10 times per day 2 to 5 times per day 6 to 10 times per day More than 10 times per day 2 to 5 times per day 6 to 10 times per day More than 10 times per day 2 to 5 times per day 6 to 10 times per day More than 10 times per day 2 to 5 times per day 6 to 10 times per day More than 10 times per day 2 to 5 times per day 6 to 10 times per day More than 10 times per day 2 to 5 times per day 6 to 10 times per day More than 10 times per day 2 to 5 times per day 6 to 10 times per day More than 10 times per day 2 to 5 times per day 6 to 10 times per day More than 10 times per day
2 to 5 times per day 6 to 10 times per day More than 10 times per day 2 to 5 times per day 6 to 10 times per day More than 10 times per day 2 to 5 times per day 6 to 10 times per day More than 10 times per day
Reference category: 0 to 1 time per day.
Patients mobilization in bed
Drugs Administration
Invasive procedures
Categories
Reference category: 0 to 1 time per day.
Care of Hygiene and comfort of patients in WC
Patients feeding
Patient lifting without mechanical assistance
Patient transfers
Patients mobilization in bed
Care of Hygiene and comfort of patients in bed
Blood pressure monitoring and glucose finger prick testing
Drugs administration
Invasive procedures
Categories
0.895
0.737
0.867
0.557
0.169
0.310
0.610
0.769
p value 0.319
Dorsal Odds ratio (CI95%) ... ... ... ... 1.909 (1.242–2.932) ... ... ... ... ... ... 1.787 (1.067–2.991) ... ... 1.691 (1.152–2.481) ... ... ... ... 1.603 (1.111–2.313) 2.129 (1.396–3.343) ... ... 1.653 (1.022–2.674) ... 1.669 (1.011–2.737) ...
Back
Shoulders Odds ratio (CI95%) ... ... ... ... ... ... ... ... ... 0.195
0.244
p value 0.194
Elbows Odds ratio (CI95%) ... ... ... ... ... ... ... ... ...
Upper limbs
Table 3 Tasks effects on upper limb symptoms in hospital nurses
Cervical Odds ratio (CI95%) ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ...
Table 2 Tasks effects on back musculoskeletal symptoms in hospital nurses
0.526
0.761
p value 0.384
0.126 0.012 0.001 0.246 0.224 0.041 0.335 0.045 0.072
0.508 0.107 0.027 0.238 0.073 0.007 0.058
0.360 0.003 0.083 0.444
p value 0.189
Wrist/hand Odds ratio (CI95%) 1.430 (1.017–2.012) 1.632 (1.078–2.470) 1.724 (1.134–2.619) ... ... 1.677 (1.079–2.608) ... ... 1.555 (1.024–2.361)
Lumbar Odds ratio (CI95%) ... ... 2.149 (1.432–3.225) ... 1.682 (1.095–2.584) 1.857 (1.264–2.728) ... ... 1.595 (1.094–2.326) 1.363 (1.020–1.820) 1.629 (1.121–2.368) 2.484 (1.395–4.424) ... ... 2.022 (1.354–3.019) ... ... 1.751 (1.102–2.782) ... ... 1.709 (1.066–2.739) 1.355 (1.014–1811 ... 2.186 (1.283–3.725) ... 1.779 (1.039–3.048) ...
p value 0.040 0.021 0.011 0.286 0.070 0.022 0.294 0.721 0.038
p value 0.080 0.193 0.001 0.188 0.017 0.020 0.614 0.146 0.015 0.037 0.011 0.002 0.520 0.290 0.001 0.535 0.119 0.018 0.124 0.064 0.026 0.040 0.318 0.004 0.137 0.036 0.400
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Low
Very high
High
Moderate
0 to 1 time per day 2 to 5 times per day 6 to 10 times per day 0 to 1 time per day 2 to 5 times per day 6 to 10 times per day 0 to 1 time per day 2 to 5 times per day 6 to 10 times per day More than 10 times per day
0.333
p value 0.468
Knees Odds ratio (CI95%) ... ... ... ... ... ...
Lower limbs
0.663
p value 0.696
0.111 (0.023–0.544) 0.071 (0.015–0.344) 0.156 (0.029–0.847)
p > 0.05
p value 0.018 0.012 0.003 0.371 0.001 0.152
p > 0.05 0.048 p > 0.05
p > 0.05
Hygiene and care of patients in bed Odds ratio (CI95%) p value p > 0.05
Ankles/feet Odds ratio (CI95%) 1.563 (1.080–2.264) 1.762 (1.130–2.748) 1.943 (1.244–3.034) ... 2.11 (1.391–3.202) ...
0.027 p > 0.05 p > 0.05 0.007 0.001 0.284 (0.082–0.988) 0.031 Reference Categories
Patients feeding Odds ratio (CI95%) p value p > 0.05
0.180 (0.040–0.821)
Invasive procedures
p > 0.05
p value p > 0.05
Table 5 Effects of tasks frequency on nurses’ symptoms intensity
Thighs Odds ratio (CI95%) ... ... ... ... ... ...
Intensity Odds ratio (CI95%)
2 to 5 times per day 6 to 10 times per day More than 10 times per day 2 to 5 times per day 6 to 10 times per day More than 10 times per day
Reference category: 0–1 time per day.
Wound treatment
Invasive procedures
Categories
Table 4 Tasks effects on lower limb symptoms in hospital nurses
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F. Serranheira et al. / Hospital nurses tasks and work-related musculoskeletal disorders symptoms
without mechanical equipment (OR = 1.709), and patient feeding (OR = 2.186). All these findings suggest that nursing tasks could be determinant factors for musculoskeletal symptoms and that the frequency in which they are performed is a major contributor for spine symptoms, particularly in the upper back (dorsal) and the lower back (lumbar) areas (Table 2). It was also possible observing that the analysed working tasks frequency have no significant effect on the likelihood of having shoulder or elbow symptoms (Table 3). However the frequency had significant effects on hands symptoms at invasive procedures, drug administration, or positioning and mobilization of patients in bed. Within those tasks with effect on wrist and hands symptoms, the one with a stronger effect was the invasive procedures (2 to 5 times per day: OR = 1.430; 6 to10 times per day: OR = 1.632 and more than10 times per day: OR = 1.724). Results from the lower limbs symptoms revealed that there is no effect of working tasks on the likelihood of having thighs or knees symptoms (Table 4). But these findings also revealed that the frequency in which invasive procedures, and wound treatment have an impact on the presence of ankles/feet symptoms. Invasive procedures had an effect when performed above 2 times a day (2 to 5 times per day: OR = 1.563; 6 to 10 times per day: OR = 1.762 and more than 10 times per day: OR = 1.943). Wound treatment had a greater effect on the same symptoms but only at a frequency of 6 to 10 times per day (OR = 2.110). After the identification of those musculoskeletal symptoms being most affected by nursing working tasks frequency (low back symptoms), we made a more detailed analysis determining the task impact on lumbar symptoms intensity. For that purpose there were analysed only the tasks that increasing the probability of having low back symptoms with an Odds Ratio equal or above 2 (Table 5). Results revealed that “patients feeding” when performed only 0 to 1 time a day relatively to more than 10 times a day decreases 82% the likelihood of having a high intensity of low-back symptoms; and decreases in 92.9% the likelihood of having a very high intensity of low-back symptoms. The patients feeding performed 2 to 5 times a day in comparison to 10 times a day decreases the probability of having very higher symptoms in 88.9%; and 6 to 10 times a day versus 10 times a day in 84.4%. The patient hygiene and comfort in bed when performed 2 to 5 times a day against more than 10 times
a day decreases the probability of having very high intensity of low-back symptoms in 71.6%. All these results reveal that nursing tasks frequency is a very important risk factor of WRMSDs, mainly those ones involving bed care. Because in a working day nurses are exposed simultaneously to almost all of the studied tasks, we also decided to test by logistic regression what is the task with greater effect on the likelihood of having low back symptoms, but in the presence of each one of the other tasks. Results revealed that invasive procedures were the most important task for the presence of such symptoms (OR = 3.264).
4. Discussion Musculoskeletal symptoms can be initiated by either muscular tension or muscle fatigue producing very often discomfort, pain and sometimes musculoskeletal disorders [25]. Identifying those musculoskeletal symptoms and their related occupational risk factors need to be addressed for the elaboration of a standard baseline allowing us to compare differences and tendencies as predictors/indicators for WRMSDs worsening, also being able to give us information on prevention of these conditions. Results showed, similarly to previous studies [14, 17–19,26,27], a high frequency of musculoskeletal symptoms in the last 12 months (cervical = 48.5%; dorsal = 45.9%; lumbar = 60.9%; shoulder = 36.2%; elbows = 7.4%; wrist/hands = 29.7%; hips/thighs = 19.5%; knees = 21.7%; ankles/feet = 24.8%). The nurses’ prevalence of self-reported musculoskeletal symptoms for the previous 12 months and for the previous 7 days, were similar with other studies [6, 17,18,26]. Low back symptoms were the most frequent and worst intensity-wise self-reported symptoms. These findings were also similar to results published in previous studies, where low back pain was described as a very frequent occupational problem in nurses, with frequencies ranging between 40% and 60% [1,17,18, 31–33]. In this study, results from binary logistic regression showed that working tasks had no effect on the increased likelihood of having shoulders, elbows, cervical, thighs and knees musculoskeletal symptoms. These results suggested that the working tasks analysed in this study seemed not to play an important role for the presence of those symptoms, perhaps being
F. Serranheira et al. / Hospital nurses tasks and work-related musculoskeletal disorders symptoms
much more influenced by other work occupational hazards, like work-related stressors, organizational factors and some individual factors, such as age, gender or BMI (body mass index) [9–11]. Nevertheless, there were tasks increasing the probability of having WRMSDs symptoms in upper back, low back, wrist/hands and in ankles/feet areas. These effects were more evident when those tasks were performed more than 10 times a day, highlighting the importance of these task frequencies. Those musculoskeletal symptoms where the tasks had a bigger influence were low back and upper back symptoms, and in a lesser way the wrist/hand and ankles/feet areas. Results suggested that those musculoskeletal symptoms in upper back, low back, wrist/hand and in ankles/feet body regions, were more associated to specific nursing working tasks, which probably means that they could be prevented with adequate risk management measures. Neck symptoms are also described as frequent WRMSDs’ symptoms in nurses [34], and it was confirmed it in this study. However, it was not identified any significant effect of working tasks on these symptoms. As a matter of fact, it was considered that further research must be developed in order to identify other possible risk factors, or results of confounding factors didn’t allow identifying any effects. Maybe some occupational-type confounders could explain those results such as the professional category, the predominance of direct contact with patients and other physical work demands not analysed. Invasive procedures were just the specific/only working task producing simultaneously effects on all lumbar, dorsal, wrist/hand and ankles/feet musculoskeletal symptoms. This may be explained by the inner characteristics of those procedures where demands from all body segments were required and, on the other hand, because it may involve some stressors exposure. Because low-back pain was the most prevalent symptom, we decided to make a deeper analysis in order to investigate the impact of working tasks (with effect on these symptoms greater than 2 (OR > 2)) on the likelihood of having increased levels of lumbar symptoms intensity. Tasks with an odds ratio greater than 2 (when performed more than 10 times per day) were: patient hygiene and care in bed (OR = 2.484); feeding (OR = 2.186); and invasive procedures (OR = 2.149). There were interesting results, since the invasive procedures were the only analysed job risk factor with no influence on the levels of low back symptoms in-
407
tensity, and patient feeding was the task with a greater effect on the worsening of such symptoms particularly when it occurred more often. Another conclusion was that patient feeding when performed only 0 to 1 time a day, compared to more than 10 times a day, decreases in 92.9% the likelihood of having very high levels of low back symptoms intensity. These results for invasive procedures may be related with the importance of this task as a stressor and also may be related with some adopted working postures. Since hospital nurses are exposed in a daily basis to a large variety of tasks simultaneously, we analysed the task with greater effect on the probability of having low-back symptoms, taking into account the other tasks effects. In this more realistic work scenario we observed that invasive procedures were the most important task for the presence of such symptoms (OR = 3.264). Concerning possible limitations, non-probability samples don’t allow a generalization of results, constituting a limitation to the external validity of this study. Regarding the internal validity, there could be a selection bias, since nurses with symptoms are more prone to answer these kinds of surveys. There could also be an information bias because our respondents might have been giving exaggerated answers if the problems in study are seen as a difficulty to their professions. Another important issue is the relationship between musculoskeletal distress or symptoms and WRMSDs. In fact, this study only demonstrated associations and not a causal relationship. Only a prospective cohort may produce more research evidence on this issue.
5. Conclusions In the present study, nursing work tasks revealed to be a very important occupational hazard for the presence of lumbar, dorsal, wrist/hand and ankles/feet musculoskeletal symptoms, being invasive procedures the only working tasks having simultaneously effects in all of these symptoms. Lower back symptoms were the most frequent selfreported WRMSDs’ symptoms and those felt with higher intensity. Tasks with a greater effect on lowback pain intensity were patient feeding and patient hygiene and care in bed. When testing simultaneously the effects of every task in the likelihood of having lower back musculoskeletal symptoms, invasive procedures were the only ones affecting the occurrence of such symptoms.
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These results for invasive procedures may be related with some adopted working postures and also with some occupational stressors exposure.
[14]
[15]
Acknowledgements [16]
We would like to thank the Ordem dos Enfermeiros and all the nurses who participated in the survey. [17]
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