To compare the prevalence of those complaints in nurses working in rehabilitation departments and nursing homes, and to evaluate factors associated with them.
To compare the prevalence of those complaints in nurses working in rehabilitation departments and nursing homes, and to evaluate factors associated with them.
A cross-sectional study in rehabilitation and in nursing home departments.
Data were obtained from questionnaires relating to basic demographics, prevalence of musculoskeletal complaints, potentially harmful positions and actions and job satisfaction.
Multivariate analyses demonstrated higher work-related musculoskeletal complaints for nurses in rehabilitation than nursing home nurses (p = .012 for low back pain; p < .001 for neck-shoulder pain). Trunk bending, static posture, repetitive tasks, and recognition of superiors were associated with low back pain. Freedom to choose work techniques and degree of diversity at work were associated with neck-shoulder pain.
Differences between the nurse groups as to work tasks might be a reason for differences in musculoskeletal complaints. Further comparisons between nurses working in different fields might reveal more accurate potential risk factors for work-related musculoskeletal complaints.
Instruction for static/awkward posture avoidance, by using mechanical aids and designing a friendlier environment, should be part of a nursing staff injury prevention strategy.
Work-related musculoskeletal complaints (WRMSC) cause considerable economic losses to individuals as well as to the community (e.g., pain medications, conventional and alternative therapies, as well as absenteeism and job turnover, etc.) (Bureau of Labor Statistics, 2009). Healthcare workers, especially those with direct patient contact, have one of the highest rates of WRMSC. For the past several decades, few studies have reported that nurses experience a high prevalence of WRMSC in the lower back (Alexopoulos et al., 2011), neck, and shoulders (Hoe, Kelsall, Urquhart, & Sim, 2012).
Pain and discomfort caused by WRMSC might significantly impact the nurse's work and private life. Changing practice habits, work settings, or even leaving the profession due to WRMSCs have been reported (Nirel, Riba, Reicher, & Toren, 2012). However, the nurse's work demands significantly vary between hospital departments and healthcare facilities. In both, there is an overlap in role function between registered nurses and licensed practical nurses. However, in hospitals, nurses have direct patient contact (patient handling tasks, e.g., moving a patient in bed, repositioning and transferring the patient) day and night, whereas in the nursing homes that participated in our study, the direct patient contact occurs only during the evening and night shifts, according to statements of the nursing directors.
Working in rehabilitation hospitals or departments and nursing homes places different demands on the physical and psychosocial aspects of the nurses (Engels, van der Gulden, Senden, & van't Hof, 1996; Waters & Rockefeller, 2010). For example, Waters and Rockefeller (2010) differentiated between patient handling tasks classified as “traditional” and those classified as “therapeutic” in a rehabilitation setting. Therapeutic tasks are designed to improve the patient's physical function and independency, whereas traditional tasks are designed to offer the patient the required help. Therefore, therapeutic tasks constitute a greater risk of musculoskeletal pain to the therapist as they require staying in an awkward position for long periods of time, thus causing higher cumulative mechanical loads on the spine.
In a rehabilitation hospital, unlike other hospitals, the nursing staff is rehabilitation-oriented, instructing patients how to independently perform their daily tasks, providing only minimal necessary help. On the other hand, nursing home nurses usually do not employ the rehabilitation approach in their practice. They expect less participation from the patients and usually do not attempt to improve patients' ability to perform their daily tasks. Nonetheless, nursing home nurses differ from other healthcare givers in their care to especially frail older patients who often suffer from cognitive impairment and behavioral problems. This may lead to potentially stressful working conditions for the staff members (Pekkarinen et al., 2013).
Accurate reporting of WRMSC prevalence and associated risk factors will enable hospitals and nursing homes to improve target interventions to areas at a high risk for WRMSC (Menzel, 2008). Surprisingly, we found relatively few studies evaluating the prevalence of WRMSC in nurses working in nursing homes (Dulon, Kromark, Skudlik, & Nienhaus, 2008; Engels et al., 1996; Horneij, Hemborg, Jensen, & Ekdahl, 2001) and in rehabilitation departments (Alperovitch-Najenson, Treger, & Kalichman, 2014). No study has as yet compared the prevalence of WRMSC and work demands between nurses working in rehabilitation departments and nursing homes.
The aims of this study were to evaluate the factors associated with WRMSC of the lower back and neck-shoulders in nurses working in rehabilitation and nursing home departments and compare the prevalence of WRMSC in nurses working in rehabilitation departments versus nursing homes.
This is a cross-sectional observational study of Israeli nurses working at the Loewenstein Rehabilitation Hospital, Ra'anana (N = 57), and in two nursing homes, Hadasim, Bnei-Brak and Beit Avraham, the Sepharadic Home for the Aged, Haifa (N = 54). Loewenstein Hospital is a large academic rehabilitation facility accepting patients from all over Israel. The nursing homes are private and include 15 nursing departments with approximately 35 patients in each department. During the data collection period, approximately 160 nurses were employed at the rehabilitation hospital and 70 at the nursing homes. It should be noted that a one-time training program in safe patient handling was given to new workers when commencing work at their various institutions. At data collection, no training was given. Moreover, during data collection most daily functions were based on manual handling. In an intervention to reduce WRMSC among the nurses in both nursing homes, we found that only about 10% of patient transfers (patients who needed extensive help), were performed with lifts. Sliding sheets were not used at all.
Nurses in every department were informed about the purpose and procedures of the study by the department head nurse and afterwards by one of the researchers. Questionnaires in the rehabilitation hospital were completed between June 2010 and February 2011 and in the nursing homes between November and December 2011. In the nursing homes, data collection was more efficient because conclusions were drawn from the former data collection. Nurses with a history of traumatic road or work accidents with major musculoskeletal injuries, pregnant or working less than a year were excluded from the study.
The study was approved by the Human Ethics Committee (Helsinki) of the Loewenstein Rehabilitation Hospital. All participants signed written informed consent.
Study participants were asked to complete a four-part questionnaire.
Age, sex, height and weight (body mass index (BMI) was calculated as weight/stature2), years of education, number of children, years of practice, years of working in the rehabilitation hospital or nursing home, working hours per week, hours of leisure physical activity, current smoking and significant chronic morbidity information (such as diabetes, hypertension, cancer, rheumatoid diseases, etc.) were collected.
The modified Nordic Questionnaire was used for data collection regarding pain, aches or discomfort in the lower back, neck and shoulders, lasting for a day or longer during the last 12 months, a dichotomous variable. This questionnaire has been shown to be reliable and valid (for office workers) and has been found appropriate for use in an Israeli population (Ratzon, Jarus, Baranes, Gilutz, & Bar- Haim, 1998).
A seven-item questionnaire, all scored on a five-point Likert-type rating scale (1 = very rare; 5 = very often) were combined to form an index of frequency of the subjects' potentially harmful positions and actions per shift found to be related to WRMSC (Pompeii, Lipscomb, Schoenfisch, & Dement, 2009; Yassi et al., 2001). A high score indicated that the participants often bent their trunk, held a static posture, experienced unexpected movements of patients, employed awkward postures, raised hands above the shoulders, worked with confused patients or performed repetitive tasks. Similar methods were previously used in studies of WRMSC in nurses (Botha & Bridger, 1998; Pompeii et al., 2009). Before data collection, we tested the reliability of the questionnaire on a sample of 14 nurses unrelated to the study. It showed moderate to high reliability (Inter Class Correlation 0.51–0.95).
A 10-item questionnaire, scored on a seven-point rating scale (1 = very dissatisfied; 7 = very pleased) was combined to form an index of overall job satisfaction, based on Shirom's translation (1988) of the Michigan Organizational Assessment Questionnaire Job Satisfaction Subscale (Bowling & Hammond, 2008). Respondents who scored high were satisfied with their work and responsibility, had the freedom to choose their own work techniques, degree of diversity at work, worked well with their peers, had good physical work conditions, good salary level, were recognized by their superiors and were satisfied with their working hours and workplace.
To compare the demographics and the 12-month prevalence (%) of WRMSC by body area between nurses (only women) in the two groups, the Mann–Whitney test was used for numeric variables and the chi-square test for categorical variables. For an adjusted effect (age, number of children, years in a rehabilitation hospital/nursing home and hours worked per week), the logistic regression was used. To adjust for significant covariates, we used the logistic regression analysis with pain in a specific area as a dependent value and age, number of children, years in a rehabilitation hospital/nursing home, hours worked per week, and further potentially risk factors, as predictors. Descriptive statistics and logistic regression analysis were used to evaluate the associations between WRMSC and potentially associated factors.
The p-value for statistical acceptance was p < .05. Data were analyzed using SPSS 17.0 for Windows (SPSS Inc, Chicago, IL, USA).
Due to differences in pain perception between the sexes (Cote, 2012) and the low number of males in this study (8 in the rehabilitation hospital and 6 in the nursing homes), we decided that only women will be included in the analysis. After exclusion criteria, 111 nurses (57 from rehabilitation; 54 from nursing homes) remained, signed an informed consent form and completed the questionnaires.
As shown in Table 1, rehabilitation and nursing home nurses differed in certain background characteristics: rehabilitation nurses were significantly older (mean age 47.55 ± 12.65 vs. 41.50 ± 12 in nursing home nurses), had more children (2.46 ± 1.58 vs. 1.76±1.23), more years of practice (24.21 ± 11.85 vs. 16.15 ± 11.86), more years in the workplace (18.19 ± 12.51 vs. 5.41 ± 5.60), but worked less weekly hours (36.35 ± 9.49 vs. 45.11 ± 14.32). No significant difference was found in BMI, leisure physical activity, smoking and significant morbidity.
|Characteristic||Mean (SD) Rehabilitation||Mean (SD) Nursing Home||Comparison (p-Value)|
|Age (years)||47.55 (12.65)b||41.50 (12)||.013|
|BMI (kg/m2)||26.84 (4.79)||26.59 (5.15)||.714|
|Number of children||2.46 (1.58)||1.76 (1.23)||.006|
|Years of practice||24.21 (11.85) b||16.15 (11.86)||.001|
|Years in a rehabilitation hospital/nursing home||18.19 (12.51) b||5.41 (5.60)||<.001|
|Hours worked per week||36.35 (9.49)||45.11 (14.32)||.006|
|Regular physical activity||45.6||35.2||.263|
|Lower back pain||52.8||39.6||.173/.012a|
Univariate analyses showed no significant differences in the 12-month prevalence of work-related lower back and neck-shoulder pain, between groups (Table 1). However, multivariate analyses, adjusted for demographic variables (age, number of children, years in a rehabilitation hospital/nursing home and hours worked per week), revealed significant differences between the groups with rehabilitation nurses having higher prevalence of low back pain (p = .012) and neck-shoulder pain (p < .001).
Further, we conducted Spearman's correlation tests to examine the associations between background characteristics and low back/neck-shoulder pain, separately for rehabilitation nurses and nursing home nurses (results also shown in a Table 1). Age (p = .001), years of practice (p < .001) and years in rehabilitation hospital (p = .001) were found to be significantly associated only with low back pain and only in rehabilitation nurses. No association was found between the background characteristics and neck-shoulder pain.
Significant associations were found between low back pain and trunk bending (p = .005; p = .013), static posture (p = .002; p = .002) and repetitive tasks (p = .013; p = .011) in univariate analyses and in logistic regression analyses (adjusted for background characteristics that were found to be statistically significantly different between rehabilitation and nursing home nurses), accordingly. No significant association was found between low back pain and unexpected movements of patients, awkward postures, hands above shoulders and working with confused patients. No significant association was found between potentially harmful positions and actions and neck-shoulder pain (Table 2).
|Patient Handling Tasks||p-Value|
|Harmful Positions and Actions||Low Back Pain||Neck and Shoulder Pain|
|Trunk bending||.005/.013 a||.931|
|Static posture||.002/.002 a||.262|
|Unexpected movements of patients||.177||.515|
|Hands above shoulders||.240||.503|
|Work with confused patients||.341||.797|
|Repetitive tasks||.013/.011 a||.522|
Only one factor of work satisfaction, the recognition of superiors, was significantly associated with low back pain (Table 3) in univariate analysis (p = .030) and in logistic regression analysis (adjusted for background characteristics that were found to be statistically significantly different between rehabilitation and nursing home nurses) (p = .038). Low back pain in nurses was not associated with responsibility, freedom to choose work techniques, degree of diversity at work, working with peers, physical work conditions, utilization of individual capabilities, salary level, working hours and the workplace in general. Association between work satisfaction and neck and shoulder pain was found only for freedom to choose work techniques (p = .024; p = .028) and for degree of diversity at work (p = .002; p = .001) in univariate analysis and in logistic regression analysis, accordingly.
|Satisfaction From:||Low Back Pain||Neck and Shoulder Pain|
|Free to choose work techniques||.089||.024/.028 a|
|Degree of diversity at work||.170||.002/.001 a|
|Physical work conditions||.223||.262|
|Utilization of individual capabilities||.537||.104|
|Recognition of superiors||.030/.038 a||.265|
Herein, we report and compare prevalence rates of WRMSC of low back and neck-shoulder pain in nurses working in rehabilitation departments and nursing homes. In addition, the association of low back and neck-shoulder complaints with physical and psychosocial work-related risk factors was examined.
Fronteira and Ferrinho (2011) in a review article stated that nurses are more affected by musculoskeletal disorders than other healthcare personnel. It is difficult to compare the prevalence of WRMSC among nurses reported in other studies as nonstandardized WRMSC evaluation methods, variations in case definitions and other methodological inconsistencies were used. Hence, we believe that it is of interest to compare the prevalence and factors associated with WRMSC using the same set of tools.
In our study, rehabilitation nurses reported significantly higher prevalence of low back (52.8% vs. 39.6%) and neck-shoulder pain in the last 12 months (56% vs. 53%) than nursing home nurses. It is interesting to note that the difference in pain prevalence between nurses in rehabilitation and nursing homes was found only in the multivariate analysis, where differences in background and professional characteristics were taken into consideration. In our study, nurses working in nursing homes were younger, had fewer children, fewer years of practice, and fewer years in the workplace than rehabilitation nurses. They also worked more hours per week. Nursing homes nurses were younger probably due to a high turnover in nursing homes (Castle & Engberg, 2005) compared to rehabilitation departments. The reasons for these differences are still under debate, but, based on the literature, we can suggest several possible explanations. Firstly, job descriptions vary between nurses in rehabilitation departments and nursing homes. In our study, nursing homes nurses scarcely lift, transfer or reposition patients in bed or onto a chair. This work is usually done by nursing aides. In contrast, rehabilitation nurses work in conjunction with the nursing aides, i.e., manually lifting patients during transfers, pushing/pulling during repositioning of patients, move equipment, push/pull heavy objects, work in non-neutral postures, and stand for long periods of time without adequate rest periods (Waters & Rockefeller, 2010). According to Waters (2010), manual handling of patients is more physically difficult than handling boxes, as people are harder to grasp.
Secondly, the number of nurses and patients, and the nurse-to-patient ratio at ward level were regarded as important factors in work satisfaction (Garretson, 2004). In the study's rehabilitation hospital, the ratio in most departments was 1 : 10 (nurses : patients) and in the nursing homes, 1 : 25. On the other hand, the nurses : nurse's aides ratio was 6 : 4 in the rehabilitation departments and 3 : 7 in the nursing homes. As there are less assistive nursing personnel and more professional nurses in rehabilitation departments, these nurses must perform extensive manual patient handling, compared with nurses working in nursing homes.
In our study low back pain was associated with trunk bending, static posture and repetitive tasks. Nurses adopt awkward postures during patient care and during maneuvering of equipment. These activities, executed in awkward back postures and high exerted forces, have been reported as causes of back complaints (da Costa & Vieira, 2010). Engels and colleagues (1996) found a strong association between back complaints and working in an awkward position. Bos, Krol, van der Star, and Groothoff (2007) found different risk factors related to different Nurses' affiliations. Static load was associated with low back pain in nonspecialized nurses but not in intensive care and operation room nurses. Trinkoff, Lipscomb, Geiger-Brown, Storr, and Brady (2003) found highest odds of reported musculoskeletal complaints in working registered nurses due to individual physical demands (i.e., working for long periods of time with the head, arms or body in awkward positions). Karahan, Kav, Abbasoglu, and Dogan (2009) identified in a questionnaire survey activities such as lifting, pulling, and bending to lift an item from floor level, as statistically significant risk factors for low back pain. Jang et al. (2007) conducted a biomechanical evaluation of nursing tasks in hospital setting, and found three major risk factors for low back injury in nurses from tasks observed in a hospital setting: weight of patients handled, trunk moment and trunk axial rotation.
We believe that instruction for static/awkward posture avoidance, by using mechanical aids and designing a friendlier environment, should be part of a nursing staff injury prevention strategy. Using mechanical aids might even reduce the perception of repetition. Interestingly, we found no association between neck and shoulder pain and potentially harmful positions and actions.
A statistically significant association was found between the freedom to choose work techniques and the degree of diversity at work and neck-shoulder pain, disagreeing with Bos et al.'s cross-sectional study (2007) that found no association between psychosocial risk factors and neck-shoulder complaints in nonspecialized nurses, intensive care nurses and operation room nurses. Numerous cross-sectional and longitudinal studies have identified psychosocial work characteristics as risk factors for neck and upper limb symptoms (Alperovitch-Najenson et al., 2014; Harcombe, McBride, Derrett, & Gray, 2010; Yu et al., 2012). Our results of association between degree of diversity at work and neck-shoulder pain are in agreement with most studies that analyzed the effect of the dimensions of the demand-control-support model (Karasek & Theorell, 1990).
Recognition of superiors was the only variable among the psychosocial factors studied found associated with low back pain. Scholey and Hair (1989) found that stressful work environment in a rehabilitation setting increased risks of low back injury. Additional studies are needed to evaluate the influence of stress and psychosocial factors on WRMSC in nurses.
Our study had several limitations. First, only female nurses were presented due to the low number of males in the data collection. It is possible that males have different prevalence associated factors of WRMSC. Further research must incorporate males and females, yet an analysis of risk factors needs to be sex-specific. Second, because of the retrospective character of the study, especially concerning WRMSC, the possibility of recall bias may be present. Third, a cross-sectional design of the study does not allow the analysis of casual relationships between WRMSC and physical and psychosocial work demands. Concerning the questionnaires, the Nordic questionnaire was not tested for reliability in nurses in Hebrew, although published recently as reliable in nurses in the Chinese language (Fang et al., 2013). The job satisfaction questionnaire was adapted as a short version from a questionnaire developed by Shirom (1998). And lastly, due to the lack of data of the nonrespondents, we were unable to perform a nonresponse analysis. For this reason, bias resulting from selective nonresponse cannot be excluded.
To the best of our knowledge, this is a first study comparing the prevalence of WRMSC of low back and neck-shoulder pain between rehabilitation and nursing home nurses. Rehabilitation nurses reported significantly higher prevalence of both low back pain and neck-shoulder pain than nursing home nurses (52.8% vs. 39.6% and 56% vs. 53%, respectively). Low back pain was associated with trunk bending, static posture, repetitive tasks and recognition of superiors; and neck and shoulder pain was associated with the freedom to choose work techniques and degree of diversity at work. In addition, different demographic characteristics between rehabilitation and nursing home nurses were found and discussed. Differences between the two groups relating to physical load might lead to different musculoskeletal complaints. Further comparisons between nurses in different fields might reveal more accurate desirable ratios between nurses, nurse's aides and patients.
The authors have no conflicts of interest to report.
The authors would like to thank the nurses, staff and management of the Loewenstein Hospital and Hadasim and Beit Avraham nursing homes for their cooperation in data collection, and Mrs. Phyllis Curchack Kornspan for her editorial services. Special thanks to Batia Halwani and Genady Murashkovsky for their assistance in recruiting the nursing homes subjects. Grant sponsors: The Legacy Foundation, Loewenstein Rehabilitation Hospital, Ra'anana, and the Israeli Ministry of Industry, Trade and Labor, Israel.
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