Open access peer-reviewed chapter
Abstract
Work-related musculoskeletal disorders are a major cause of morbidity in nursing. They include a range of signs and symptoms that can affect the quality of performance of work tasks and quality of life. Workplace risk factors can generally be divided into biomechanical (physical), psychosocial, sociocultural, individual (personal), organisational, and environmental risk factors. The risk factors are numerous and interact positively and negatively with each other. There are various methods and tools for assessing work-related risk exposure or risk factors in the workplace. In general, the methods for risk assessment of work-related musculoskeletal disorders can be categorised as self-report, (expert) observation, direct measurement, and remote sensing. When selecting assessment tools, we must consider their measurement characteristics as well as financial and time constraints, the characteristics of the researchers, the clients, and the environment. The assessment of risk factors forms the basis for the development of intervention measures to reduce and/or prevent work-related musculoskeletal disorders. The intervention framework usually consists of a sequence of several steps. Given the dynamic nature of change in work-related musculoskeletal disorders, this process is iterative and continuous and is likely to be most effective when individualised. Healthy employees in a well-functioning work environment should be the goal in every workplace in the healthcare system.
Keywords
- work-related musculoskeletal disorders
- nursing
- risk factors
- intervention
- prevention
1. Introduction
Musculoskeletal health refers to the performance of the musculoskeletal system, which consists of intact muscles, bones, joints, and neighbouring connective tissue [1]. Musculoskeletal disorders (injuries or disorders of the muscles, nerves, tendons, joints, cartilage, and spinal discs) are the most common causes of disability and limitations in daily life and employment [2]. Around 1.7 billion people on the planet suffer from musculoskeletal disorders, such as back pain, neck pain, fractures, and other injuries, as well as osteoarthritis, rheumatoid arthritis, and amputations [3]. The prevalence of musculoskeletal disorders in the general population varies considerably depending on country, occupation, and sociodemographic factors [4, 5]. Work-related musculoskeletal disorders (WRMSDs) are conditions in which the work environment and work performance contribute significantly to the condition and/or the condition is exacerbated or prolonged by working conditions [6]. The definition of WRMSDs is any musculoskeletal problem that occurs at work and causes discomfort, difficulty, or pain in performing the job [7]. It refers to muscle, nerve, or other soft tissue injuries or disorders caused by workplace-related risk factors [8]. The term refers not only to medically based periarticular disorders of the limbs and spine (specific WRMSDs) but also to multiple or localised pain syndromes (non-specific WRMSDs) [9]. WRMSDs are the largest contributor to the work-related burden of disease and are largely related to ergonomic factors in the workplace [4]. WRMSDs are sometimes referred to as cumulative trauma disorder or disease, repetitive strain injuries, overuse syndromes, regional musculoskeletal disorders, repetitive motion injuries, and soft tissue disorders [10]. The aetiology of WRMSD is complex as it encompasses physical, psychological, social, and spiritual aspects of the work environment.
2. Methods
This narrative literature review is intended to discuss the relevant literature that has studied work-related musculoskeletal disorders in nursing, their prevalence, risk factors for occurrence, and interventions for their reduction and/or prevention. Narrative literature review covered a broad range of topics by using studies of various complexity and design. A search was conducted in December 2023 in the databases PubMed, Google Scholar, and ScienceDirect. The search terms were “work-related musculoskeletal disorders AND nursing”. Inclusion criteria were the empirical research and review articles to contextualise the findings and freely available articles in their entirety.
3. Results
A total of 200 articles were initially identified to be potentially relevant for the review. A total of 150 articles were included, and they were found to match the inclusion criteria.
3.1 Prevalence of work-related musculoskeletal disorders in nurses
WRMDs are very common among healthcare professionals. Nursing is at the top of all professions, with the potential to develop WRMSDs [11]. A prevalence of over 80% was found in physiotherapists [12], masseurs [13], dentists [14], surgeons [15], midwives [16], and nurses [17]. The prevalence of WRMSDs among nurses is in some cases higher than in other occupations, such as production workers and doctors [18, 19], ranging from 60 to 98% [20, 21], and varies widely due to the more or less complex work in primary, secondary, and tertiary healthcare, depending on the departments, the hospital, and even the countries in which they work [22, 23], which seems to be related to many different occupational exposures of nurses to WRMSDs [24]. The high exposure to WMSDs is directly related to their job, which requires multiple tasks and high physical exertion [25]. They affect the quality of life [26] and lead to varying degrees of long-term illness, work restrictions, high treatment costs, absenteeism, disability [27], patient safety issues, and reduced quality of care [28, 29]. Nurses with WRMSDs have a higher risk of depression [30] and a higher tendency to turnover [31]. In this population, compensation payments, diagnostic testing, and medical services can cost between $50,000 and $100,000 per musculoskeletal injury [32], and WRMSDs are also a major cause of sick leave.
The prevalence of WRMSDs can vary from 33.0% to 88.0% among nurses around the world [33, 34] or from 60–95% [35, 36].
3.2 Prevalence of work-related musculoskeletal disorders by body region
The neck and lower back were the most afflicted regions across all healthcare occupations, with an average frequency of between 26.7% and 70.1% [25]. Compared to dentists and surgeons, nurses had a lower average prevalence for the neck (33.1%) [37]. The most common complaints among nurses are lower back, shoulder, neck [38, 39, 40], hands, and legs (Figure 1) [38, 39]. The prevalence of WRMSDs on the feet and the whole body was higher in developed areas than in developing areas. Conversely, the prevalence of WRMSDs at other anatomical sites was higher in developing areas than in developed areas [33]. WRMSDs in the neck, upper back, and other anatomical sites decreased over time, while the prevalence of WRMSDs in the shoulder and knee showed an increasing trend [33].
Figure 1.
Annual prevalence of WMSDs in different anatomical sites by prevalence rate (adopted from ref. [
3.3 Risk factors
WRMSD is a multifactorial phenomenon influenced by various [41] direct and indirect risk factors (Figure 2). The nursing profession is a very demanding occupation (physically, psychologically, socially, and mentally), which makes nurses more vulnerable to WRMSD. Due to the complexity and abundance of risk factors, researchers usually opt for a framework that narrows the field and facilitates understanding of their interplay. In the workplace, these factors can generally be divided into biomechanical (physical), psychosocial, sociocultural, individual (personal) [42, 43], organisational, and environmental risk factors.
Figure 2.
Dynamic relationship between workplace risk factors for WRMSDs. All risk factors influence each other, either inhibitory or facilitative.
3.3.1 Physical and biomechanical factors
Physical and biomechanical risk factors include repetitive movements, carrying heavy objects, unfavourable postures [44], patient handling, and long working hours [45, 46, 47]. Patient handling tasks were documented as the main factors for WRMSD in nursing staff. Perceived physical demands that carers are frequently exposed to include moving objects, pulling/pushing machines, lifting patients, repetitive movements, and extreme bending, bending, twisting, and sudden movements [48]. Highly repetitive activities on a continuous basis can trigger WRMSDs [49]. These physical demands increase the risk of complaints in various parts of the body [50, 51]. WMSDs have been shown to be associated with patient-handling tasks in nurses [52, 53].
3.3.2 Psychological and social factors
The interactions between the work environment, job content, organisational conditions and skills, needs, and personal considerations outside of work that can affect relationships with patients (clients), job performance, and health are referred to as psychosocial factors at work [24]. Nurses who have at least one WRMSD in one body segment have expressed dissatisfaction with their profession, citing poor nurse-physician contact, staff disengagement, and lack of support from immediate superiors [54]. Nurses may face various types of difficulties during their work that contribute to WRMSDs [55], including psychological distress [46, 47], problems with patients, problems with management and physicians [55], lack of support from others, lack of decision-making power [56], anxiety, and depression [46, 47]. Unfavourable psychological and social factors led to an unfavourable work attitude, shortened time interval between rest and activity, and possibly reduced cooperation with colleagues, thereby reducing workers’ ability to resist WMSD [57].
Spirituality refers to a sense of connection between the individual and the universe, the meaning of life, purpose, integration, growth, truth, and mindfulness [58]. Today, more and more organisations are recognising the importance of spirituality in the workplace. It is about finding meaning, value, and motivation in one’s work to achieve better performance and care outcomes [59]. Spirituality in the workplace is becoming an essential aspect of healthcare. It has numerous benefits, such as improved overall employee well-being, higher employee productivity, increased motivation and job satisfaction, engagement and team effectiveness, and team cohesion [60]. Spiritual stress can also have a direct impact on health. Research indicates that those exhibiting comparatively elevated levels of spiritual distress are more prone to experiencing pain, depression [61, 62, 63, 64], suicide risk [62, 63, 64], higher levels of clinically effective anxiety [63, 64], and a higher resting heart rate [64]. Spirituality in the workplace has integrated some spiritual concepts such as inner connection, sense of community, connectedness, compassion, transcendence, and mindfulness in the workplace to improve employees’ mental health and well-being, increase their engagement and motivation, and improve organisational outcomes of companies [65]. It has been demonstrated that workplace programmes rooted in spirituality offer a multitude of advantages to both workers and employers. These advantages include heightened creativity and revenue, elevated productivity and performance, decreased absenteeism, and elevated levels of intrinsic motivation and job satisfaction [66]. By incorporating spirituality into workplace health promotion programmes, employees can be supported by their organisations in managing burnout, work-related stress, and violence, as well as other psychosocial risk factors in the workplace [67].
3.3.3 Factors in the organisation of work
There is evidence that the development of WRMSD is highly related to work organisational factors, including problems with scheduling [68, 69], shift work, staff shortages, poor working conditions [46, 47], and extended working hours [17, 70], which may be risk factors contributing to the development of WRMSD in nurses. Nurses are at very high risk for WMSD due to the shift-heavy culture and long working hours in this field [71, 72]. Hale and Hovden [73] have identified three stages in the development of occupational health and safety management, with the third stage characterised by the consideration of organisational and management issues as fundamental factors in improving safety. This suggests that what matters is how well an organisation’s culture is established and communicated to employees to facilitate their working relationships. The term “organisational factors” encompasses all the elements that influence the way the organisation and each individual within it behaves. Typically, these elements include:
formal management systems (e.g., safety and competence management),
assurance processes (monitoring, audit, and review),
work practises, regardless of whether they are formally documented or not,
risk awareness,
how the organisation has learned from experience,
safety culture of the organisation.
There is a direct, significant relationship between organisational culture and job performance, and a strong, employee-friendly organisational culture can lead to effective employee performance [74]. Organisational culture and performance are two variables that are significantly correlated [75, 76].
3.3.4 Environmental factors
As the authors of [77] previously explained, the idea of healthy buildings is a biopsychosocial framework that focuses on redesigning the built environment to promote and improve occupants’ health, well-being, performance, productivity, and quality of life. The interior design of medical facilities is unique. Interior design aims to create a therapeutic environment for patients and make their stay in a facility as non-threatening, comfortable, and stress-free as possible. However, the needs of patients are often at odds with the needs of staff in medical facilities [78].
Environmental influences include light sources and levels that deliver too much or too little light, cold or too warm temperatures, noise levels [79], humidity, and biochemical dangers. These conditions have a negative impact on employee health. Research indicates that environmental variables, like uncomfortable temperatures, can play a major role in the onset and aggravation of WRMSDs [80, 81]. In addition to having a negative impact on workers’ health (including musculoskeletal symptoms) and job performance, heat stress [82] and cold stress [80, 81] can also increase psychological distress and mental health issues [83, 84], lower key human psychological performance variables [85], and cause irritability, inattention, a sense of exhaustion, and mood swings. Current findings suggest that hot and cold temperature exposure negatively affects performance and that other variables (e.g., duration of temperature exposure or task duration) can alter this relationship [86]. Increased noise in the workplace [87], insufficient availability of light [88], dry air, and temperature fluctuations [89] were also significantly associated with an increased risk of WRMSD. Biological (experience with cuts/wounds/injuries, airborne infections, physical contact with retroviral patients and specimens, and exposure to blood-borne specimens), chemical, and radiation hazards to which nurses are exposed and their association with WRMSD have not been adequately studied.
3.3.5 Individual factors
Individual (personal) factors include age, gender, body mass index, lifestyle issues, and living conditions [90]. WRMSDs are common among nurses and primarily affect the lower back. The likelihood of developing WRMSDs is high with increasing age, BMI, and work experience, as well as among nurses working in intensive care units and public hospitals. Some studies confirm such an association between nurses’ age and WRMSDs (especially neck, arms, and lower back) [91, 92], while others contradict these findings [93, 94]. It was not age but rather high physical job demands that significantly increased the risk of WRMSD in all age groups [95]. Differences in workload, biological status, and body size between men and women may be connected to the correlation between gender and musculoskeletal discomfort [96, 97]. Compared to normal-weight workers, obese workers had a higher risk of developing WRMSDs and a lower recovery from symptoms [98]. The rate of WRMSDs increases significantly with increasing work experience [96, 99]. The physical abilities (muscle strength) that enable people to cope with physical job demands naturally decline over time due to age [100]. Physically demanding nursing professions with long working hours and shift work can contribute to nurses being less physically active in their free time [101]. Studies suggest that physical activity at work and in leisure time may not have the same health benefits, although the results vary [102, 103]. Given their strong correlation with six of the seven factors contributing to early death [104], physical exercise at the proper degree and intensity, as well as a nutritious diet are regarded as the most significant positive health behaviours in preventive healthcare [105]. It is very likely that physical activity during leisure time, with appropriate parameters, can prevent musculoskeletal disorders, especially in nurses with long work experience [106].
3.4 Risk factors assessment
There are various methods and tools for assessing work-related risk exposure or for identifying potentially hazardous workplaces or risk factors in the workplace. In general, WRMSD risk assessment methods can be categorised as self-reporting, (expert) observation, direct measurement, and remote sensing (Figure 3). Risk assessments should be carried out using methods that are objective and accurate, that is, reliable and valid. Risk analyses can also be carried out when evaluating the effect of a measure in the workplace.
Figure 3.
Schematic presentation of the assessment methods of body workload (OWAS – Ovako Working Posture Analysing System [
Self-report was originally developed to assess WRMSD problems and is widely used in epidemiological and ergonomic studies [114, 115]. Sometimes, it is a face-to-face interview between the workers and an investigator. This method is easy to use with large groups of workers and allows comparisons over time and between groups. However, self-reporting takes time and interrupts employees’ ongoing work. Internet surveys, video recordings, and video conferencing have also been used to improve the efficiency and accuracy of the self-reporting process. Self-reporting has the benefit of allowing many employees to report on concerns and difficulties that are challenging to see (such as pain and perceived workload), and it is an economical and flexible strategy that can be used in a variety of work environments. Self-reporting has the drawback that as the results are dependent on subjective assessments, they can differ greatly between individuals. Furthermore, survey replies may be skewed because of personal ramifications, which calls into question the validity of this approach, considering alternative approaches like direct measurement and sophisticated sensing techniques [116].
The methodical documentation of postures during work, including location, frequency, intensity, and duration, is called observation [115]. WRMSD hazards for a possible job or work environment redesign are normally measured by specialists using assessment forms and an experienced observer. Although these techniques take longer, their validity and reliability have been determined to be acceptable [117].
Direct measurements are more objective than expert views and self-reports. In order to analyse biomechanics and tissue and joint loads, common direct measurements include electromyography, optical markers, goniometers, inclinometers, optical scanners, and sound sensors. Recently, numerous new technical methods for observing postures, movements, and loads have been developed. These instruments are generally very accurate but also have some disadvantages. They are more expensive than observation methods, need to be operated by experts, and interfere with the organisation’s work.
Modern remote sensing methods use distance or image/video sensors to record human motions using marker-less sensor-based biomechanics. Motion or kinematic data can be gathered and used as input for biomechanical modelling, which computes joint or tissue loading – a factor that is strongly correlated with WRMSD risks – as well as for the observational risk assessment techniques already in use to establish the degree of risk in the field. These methods can be utilised for assessments in actual workplaces because they do not require human participants to be directly attached to markers or signal receivers [118]. Because sensor-based approaches can record objective, precise movement data that may be used to predict joint loads, they have an advantage over self-assessment and observational methods.
When selecting assessment tools, we need to consider not only their measurement properties but also the financial and time constraints, the characteristics of the researchers, the clients, and the environment (Figure 4).
Figure 4.
Graphic representation of guidelines for decision-making on the selection of assessment tools.
3.4.1 Interventions to reduce work-related musculoskeletal disorders
Four categories (specialised equipment, staff training, policies and procedures to reduce work-related musculoskeletal illnesses, and support and follow-up) can be used to categorise the interventions documented in the literature [119].
The introduction of handling equipment, also known as specialised equipment, lifting devices, repositioning devices, and handling equipment, was a prominent trend among the treatments. These included fast-ascending electric beds, sliding boards, overhead lifts (also known as mechanical lifts) [120, 121], and overhead lifts [122]. Positive results from all of these various tactics included a decrease in injuries [119].
The staff training programmes with the most positive outcomes were designed and delivered by care facility management [120, 122]. Conversely, Peterson et al. [123] found no significant reduction in pain, discomfort, or the general physical and mental health of participants after training.
Training programmes for correct posture, physical exercise, and redesign of the work environment by staff were also used to reduce stressful boot postures [124]. Gold et al. [121] also supported physical exercise training to improve flexibility and prevent or reduce low back pain, particularly in individuals with a history of low back pain.
Adherence to specific policies and procedures guiding mobility interventions in care homes reduced work-related musculoskeletal disorders [120, 121]. The introduction of these guidelines took into account the availability of specialised equipment and centred on its appropriate use and maintenance, such as the prompt cleaning of slings and battery recharging. These measures significantly impacted the correct use of specialised equipment and further decreased the rate of injuries [119].
To promote compliance with the use of specialised equipment, measures were initiated to comply with training programmes, implement guidelines as a follow-up, and support staff in a multidimensional environment [119]. The utilisation of therapy sessions as a follow-up technique to avoid musculoskeletal diseases connected to employment was another supportive intervention [125, 126].
Workplace physical activity, or physical activity at work, is a form of organised physical exercise that tries to establish areas where employees can spontaneously take a break from their monotonous schedule to exercise their body and mind and grow in self-awareness, which can enhance their connection with the workplace [127]. The main goal of physical activity in the workplace is to improve performance during the working day and prevent musculoskeletal disorders. Depending on the time of day or purpose, different physical activity modalities can be used in the workplace [128]. Physical exercise can be performed at the beginning of work and is referred to as preparatory, as its main purpose is to warm up the whole body before starting the job tasks [129, 130, 131]. Because compensatory movement in the workplace entails stopping work duties to move around, it is often referred to as a short active break [132]. These pauses are intended to alleviate tension in the musculoskeletal system (joints and muscles) brought on by task-related variables and to make up for bad posture. Workers’ physical and emotional well-being depends on this kind of mobility [133]. At the conclusion of the workday, employees should practice relaxation techniques [134]. It can also be used in conjunction with mind-body interventions, such as progressive muscle relaxation, acupuncture, yoga, Pilates, and meditation, as complementary therapies [135]. There is consistent evidence that physical activity in the workplace significantly reduces general musculoskeletal pain and neck and shoulder pain [136].
3.4.2 Prevention of work-related musculoskeletal disorders
In many countries, the population is ageing, and the retirement age of the labour force is increasing [137]. There is a general tendency for the incidence of WRMSDs to increase with age [138], but work-related hazard exposures significantly accelerate this age-related increase [139].
There is a growing urgency for workplaces to adopt evidence-based risk management practices that more effectively reduce WRMSD risk [140]. Given the influence of multiple risk factors on the occurrence of WRMSDs, the implementation of prevention and control programmes and measures requires the simultaneous identification and control of a range of risk factors [44]. Hazards are best eliminated at the source. This is a fundamental principle of occupational health and safety. Despite knowledge of the factors associated with WRMSDs, primary prevention measures for WRMSDs through changes in work-related physical factors, such as manual handling advice [141] and ergonomic workplace design [142], have not been shown to be effective or too successful in preventing WRMSDs. In addition, the global burden of WRMSDs appears to have increased rather than decreased in recent years [143], although many preventive measures and strategies exist (e.g., workplace measures or ergonomic guidelines). The latter does not apply to all topographical areas [144]. Theories and/or programme failures, such as inadequate translation of information about aetiological mechanisms into well-crafted intervention programmes, may be to blame for the failure of WRMSD prevention efforts [145]. For these reasons, a framework for WRMSD prevention research using a repeated sequencing approach was proposed by van der Beek et al. [146]. It is based on the “risk identification, assessment, control and evaluation framework”, which serves as a foundation for international labour policy and practise [147], as well as similar frameworks from other research fields [148, 149, 150]. There are six steps in the suggested framework (Figure 5).
Figure 5.
Suggested a recurring protocol to prevent musculoskeletal diseases associated with the workplace. The steps should ideally be followed in order, beginning with step 1 and concluding with step 6 (solid lines), after which it can be repeated. As an alternative, one could go back to steps 2, 3, or 4 (dashed lines) if interventions in step 5 have not shown to be successful (adapted from [
In line with the authors’ findings [146], this framework has the potential to enhance existing theories and bolster the creation and execution of preventive measures for WRMSDs. The development of interventions in research based on an identified problem (step 1) and targeting risk factors that seem to be associated with a WRMSDs problem (step 2), possibly with a solid understanding of the underlying mechanisms and pathogenesis (step 3), is necessary to achieve the best possible outcome in the prevention of WRMSDs [146]. A demonstrated effective preventive intervention (step 5) should be fully implemented using evidence-based implementation strategies (step 6), while the intervention should also be optimally targeted to the particular occupational population and work environment (step 4) [146]. In order to successfully execute changes in the workplace, it is crucial.
4. Discussion
Numerous studies have been conducted on WRMSD in workers across a range of industries, including the nursing field. The majority of cross-sectional, retrospective, or prospective investigations have shown that WRMSD is quite prevalent in nurses. Studies on the incidence are scarcer. Numerous risk factors for the development of WRMSDs are present in nurses. Most research focuses on physical stress at work as one of the primary risk factors; however, social, psychological, and spiritual elements – especially the ways in which they interact with one another – are sometimes overlooked. There are many programmes aimed at lowering the incidence and primary prevention of WRMSD; nevertheless, their effectiveness is frequently minimal or transitory. The majority of these interventions overlook the individuality of each worker in favour of targeting a larger group of workers, or average workers, and they disregard each person’s individuality. Like diseases, WRMDs are a dynamic process. To lessen their impact on society at large and on healthcare workers specifically, regular interventions based on frequently repeated analyses of the work organisation, the demands of work processes, and the worker—who also changes over time—are likely to be most effective.
5. Conclusions
With low back pain and ankle/foot pain having the greatest prevalence rates, neck and shoulder pain following, and elbow pain having the lowest prevalence rate among the 13 body locations included in the study, WRMSD is highly prevalent among nurses. The primary risk variables for WRMSD were age, gender (female), high body mass index, and length of employment. These association patterns also provide insight into potential intervention tactics to enhance a positive psychosocial work environment and encourage a healthy lifestyle. Appropriate screening programmes for musculoskeletal pain risk factors among nurses should be implemented, and prevention, early diagnosis, treatment, rehabilitation, and counselling are needed. Solutions could also include increasing staff numbers and rescheduling working hours by the health manager or senior management. Healthy employees in a well-functioning work environment should be the goal in every workplace in the health care system.
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