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Nursing Work and Life
Predisposing factors for musculoskeletal symptoms in intensive care unit nurses D. Sezgin1
MSc
& M.N. Esin2 PhD
1 Lecturer, Nursing Department, Faculty of Health Sciences, Bezmialem Vakif University, 2 Associate Professor, Public Health Nursing Department, Faculty of Nursing, Istanbul University, Istanbul, Turkey
SEZGIN D. & ESIN M.N. (2015) Predisposing factors for musculoskeletal symptoms in intensive care unit nurses. International Nursing Review 62, 92–101 Introduction: Intensive care unit nurses have more ergonomic risks than nurses working in other units in hospital. Background: Although musculoskeletal disorders are common among intensive care nurses, studies on the prevalence of symptoms, as well as associated factors, are scarce. Aim: This is a cross-sectional study to investigate the prevalence of musculoskeletal symptoms and associated factors in intensive care nurses. Methods: The study population comprised 1515 nurses working in the intensive care units of public, private and university hospitals in Turkey. The study sample included 323 nurses selected by stratified random sampling. Data were obtained by a tailored data collection form, a workplace observation form and a Rapid Upper Limb Assessment tool to delineate ergonomic risks. Statistical Package for the Social Sciences 21.0 software was used in the statistical analysis. Results: The highest prevalence for the musculoskeletal symptoms of the nurses was in the legs, lower back and back. Most of the nurses had encountered musculoskeletal pain or discomfort related to the previous month. The risky body movements that were frequently performed by the nurses during a shift were ‘turning the patient’ and ‘bending down’. Discussion: The final Rapid Upper Limb Assessment score for the patient turning movement was found to be higher than for the bending down movement. Conclusions: Musculoskeletal symptoms, which may occur in any region of the body, are mainly associated with organizational factors, such as type of hospital, type of shift work and frequency of changes in work schedule, rather than with personal factors. Implications for Nursing and Health Policy: Nursing administrators should determine the ergonomic risks of intensive care unit nurses by using Rapid Upper Limb Assessment tool. Health policy makers should develop occupational health teams, and ‘ergonomic risk prevention programs’ should be implemented throughout the units.
Correspondence address: Melek Nihal Esin, Public Health Nursing Department, Faculty of Nursing, Istanbul University, Abide-i Hurriyet Caddesi, Istanbul 34381, Turkey; Tel: +90-212-224-49-86; Fax: +90-212-224-49-90; E-mail: [email protected].
Funding source This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. Financial costs were covered by the researchers. Conflict of interest No conflict of interest has been declared by the authors.
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Keywords: Ergonomic Risks, Intensive Care Nurse, Musculoskeletal System, Nursing injuries, Back injuries, Rapid Upper Limb Assessment, Occupational Health
Introduction Musculoskeletal disorders (MSDs) are the most common health problems in all work-related disabilities and injuries. Two factors are important in the development of occupational MSDs, namely ‘repetitive strain’ and ‘cumulative trauma’. In the long term, muscle, bone or tendon injuries may occur or develop as a result of acute excessive straining (Côté et al. 2013; Tullar et al. 2010). Nurses repeat movements such as pushing, pulling, elevating and bending too much in their work environment, as a result of which, MSDs may easily develop (Lee et al. 2013; Long et al. 2012). The main injuries affect the cervical level, the lower cervical spine, the thoracic spine, the thoracolumbar junction, and the lumbar and sacral vertebrae (Chung et al. 2013; I˙lçe & Dramalı 2010). Intensive care units (ICUs) are identified as having the highest occupational risk in terms of ergonomic risk (American Association of Critical Care Nurses (AACN) 2013; Black et al. 2011). MSD development in ICU nurses is caused by physical and psychosocial factors, such as standing for long hours, daily workload, working in shifts, dissatisfaction with work, caring for patients with co-morbidities, frequently encountered deaths, interaction with families of patients and inadequate income (American Association of Critical Care Nurses (AACN) 2013; DeCastro et al. 2010; European Foundation for the Improvement of Living and Working Conditions (EFILWC) 2010; Lemo et al. 2012). In addition, personal factors, such as ageing, inadequate physical condition, smoking and obesity, are important in the development of MSDs (Black et al. 2011; Tullar et al. 2010). Generally, ICU nurses have more risks than nurses working in other hospital units (Pınar 2010).
Background The prevalence of musculoskeletal injuries in nurses and other healthcare professionals due to patient handling tasks was found to be between 40% and 84% in developing and developed countries (Carugno et al. 2012; Chung et al. 2013; Freimann et al. 2013; Harcombe et al. 2009; Munabi et al. 2014; Tinubu et al. 2010). The frequency of musculoskeletal symptoms in the previous 12 months were found to be 80.8% and 78.0%, respectively, in sub-Saharan African countries such as Uganda and Nigeria (Munabi et al. 2014; Tinubu et al. 2010). The prevalence of musculoskeletal pain reported in the previous
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month was 69.0% in Estonian nurses, and 76.24% of the nurses working at hospitals in Taiwan had musculoskeletal injuries (Chung et al. 2013; Freimann et al. 2013). In the studies performed on nurses from Italy, Brazil and New Zealand, the prevalence of MSDs were found to be 49.1%, 45.1% and 40.0%, respectively (Carugno et al. 2012; Harcombe et al. 2009). In Turkey, the prevalence of MSD symptoms in nurses was found to be 79.5% in hospital nurses, and ICU nurses were found to be more likely to suffer from MSDs than other nurses (Pınar 2010). Studies investigating the ergonomic risks, MSDs and related factors in ICU nurses are scarce, however, and generally depend upon self-reporting and determination of MSDs in regions such as lower back, shoulders and back (Black et al. 2011). Ergonomic risks that have the most significant impact on MSD development should be determined with valid and reliable measurement tools. Studies in which such tools are used are also scarce. The Rapid Upper Limb Assessment (RULA), which was used to obtain the data in this study, is a reliable tool extensively used by investigators in measuring ergonomic risks.
Aim This study was conducted to determine the prevalence of musculoskeletal symptoms in ICU nurses and to delineate their risk factors. The questions to which we intended to find answers were as follows: • What is the prevalence of MSD among ICU nurses, according to answers obtained with a tailored data collection form? • What are the ergonomic workplace risk factors among ICU nurses, according to data obtained with RULA? • What are the predisposing risk factors for MSD development in ICU nurses?
Methods Setting
This cross-sectional study was organized in hospitals in the European and Asian parts of Istanbul, which is a cosmopolitan, densely populated and economically rich city in northwestern Turkey. Many patients from other regions of Turkey, and lately from other countries as well, come to Istanbul. There were 281 hospitals (public, private and university hospitals) in Istanbul during the period when this study was conducted. Data for this study were obtained from 51 adult ICUs (general, coronary, car-
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diovascular surgery and reanimation) in 17 hospitals, where ergonomic risks such as weight-lifting are considered to be high. Sample
A total of 1515 nurses work at these 51 ICUs. The sample size was calculated by the formula n = Nt2pq/d2(N − 1) + t2pq (t:1.96, d:0.05, P = 50%, q = 1 − p), yielding 306 nurses. When data loss was taken into consideration, the final sample size was set at 350 nurses. The nurses were selected by stratified random sampling. As the working conditions of the strata are different, the nurses were stratified according to public, private and university hospitals. The procedure was to select a sample randomly from each stratum that was proportional to the stratum’s size in relation to the population. The strata weights and the number of nurses from each strata are shown in Table 1. Sample selection was performed using a simple random sampling method. The lists of nurses working at each hospital were obtained from the respective hospitals. Thirty-three ICU nurses from the first stratum and one ICU nurse from the second stratum could not be reached during the study. All the nurses intended for selection from the third stratum were reached, and an additional seven nurses were included in the sample. Thus, 323 ICU nurses comprised the sample. Data collection methods
The data were collected during the period between 8 February and 20 March 2012 by observation and personal interviews. Tailored data collection form
The form was constructed in accordance with the Nordic Musculoskeletal Questionnaire, which was developed by McAtamney & Nigel Corlett (1993). It consisted of five sections. The first section included questions on demographic characteristics: gender, education, age, marital status and living with children; the second included questions on working conditions: type of hospital/ICU, daily workload, type of shift work, frequency of changes in work schedule, total years in nursing/ICU nursing, daily/weekly working time; the third included ques-
tions on psychosocial characteristics: income and work satisfaction, relationships with colleagues and managers, feelings of being under pressure due to work; the fourth section included questions on ergonomic risks: ergonomic training programmes, frequency of exercise, lifting weights outside of working hours, adequate assistance from support staff; the last section included questions on general health status: cigarette smoking, general health perceptions, MSD symptoms, diagnosed MSDs and intensity of pain. The nurses were requested to specify, on a body discomfort chart, the regions where they had felt any symptoms of MSD in the preceding month. They were also asked to score the intensity of pain on a visual analogue scale. Work environment evaluation observation form
This form was developed by the investigators, based upon the relevant literature, in order to evaluate the physical and ergonomic appropriateness of the workplace environment of ICU nurses. Criteria such as patient transfers done by stretcher or patient bed, presence of a sufficient area for bedside support units and presence of lifts for patient transfer were included in the observation form. RULA
Data on the ergonomic risk factors of nurses were obtained by direct observation using the Rapid Upper Limb Assessment (RULA), which is a validated tool used to diagnose work-related upper limb disorders, biometrical and postural loading (McAtamney & Nigel Corlett 1993). The Turkish validation of RULA was performed in 2007 (Öztürk & Esin 2007). When RULA is used, calculations are made in relation to the posture of the various body parts. Score A combines the scores relating to the two limbs as well as the wrist scores. The scores relating to neck, trunk as well as legs are covered in score B. A score of 1 or 0 relates to the positioning of the muscles in use or force that is exerted to the same when they are in a working situation. When 1 and 0 scores are added to A and B scores, the result obtained is C and D scores. The grand scores are arrived at by summing the C and D scores. Low grand scores
Table 1 Number of selected nurses with stratified random sampling Stratum No.
Hospital type (number)
Number of nurses
Strata weights
Number of nurses to be selected
Number of selected nurses
1 2 3 Total
Public hospital (9) University hospital (2) Private hospital (6) 17
950 265 300 1515
950/1515 = 0.62 265/1515 = 0.18 300/1515 = 0.20 1.00
0.62 × 350 = 217 0.18 × 350 = 63 0.20 × 350 = 70 350
184 62 77 323
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(1 or 2) show the ‘acceptable’ work posture. It is recommended that action be taken in cases of higher scores. For grand scores of 3 or 4, further analyses may be recommended and modifications to improve the score should be made if required. Immediate analyses and modifications are suggested for grand scores of 5 or 6. Also, analyses and modifications should be performed promptly for a grand score of 7 (McAtamney & Nigel Corlett 1993; Öztürk & Esin 2007, 2011). Data analysis
Statistical Package for the Social Sciences version 21.0 software, licenced to Istanbul University (IBM Corp., Armonk, NY, USA), was used in the analysis of the data. The general characteristics and ergonomic risks of the nurses were displayed as number, percentage and mean. Chi-square test and logistic regression analysis were used in the evaluation of the association between these characteristics and MSD symptoms. Estimation was made at odds ratios and at a degree of confidence of 95% to find out the risks and prevalence of musculoskeletal symptoms in unadjusted logistic regression models. Ethical issues
Ethical approval was obtained from the Ethics Committee of Istanbul University Institute of Cardiology before initiating the study (Protocol No. 2012/02). All of the nurses signed informed consent forms.
Results General characteristics
Of the nurses participating in this study, 79.3% were female and 48.3% had a bachelor’s degree, whereas 60.4% were single, 86.7% were aged between 21 and 35 years (mean age 27.9 ± 5.1) and 76.8% were ‘not living with children’. A past diagnosis of MSD was present in 18.3% of the nurses. The most frequent MSD was defined as ‘spinal diseases’. Work and workplace characteristics
Weekly total work duration was (mean) 47.2 ± 8.9 h; 32.8% of the nurses were working at a cardiovascular surgery ICU. Total years in nursing (mean) were 6.4 ± 4.9 years and the total duration of standing in a shift was 8.2 ± 1.9 h. Of the nurses, 71.8% could have breaks during the day, and the duration of work until a break was 5.9 ± 2.8 h. Whereas 65.3% defined their relationships with colleagues and managers as ‘reasonable’, 38.1% ‘occasionally’ felt pressured by work. Of the nurses, 80.2% reported not attending an ergonomic training programme at their institution at any time. Whereas
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40.2% of the nurses reported ‘occasionally’ lifting weights outside of working hours, 44.9% ‘occasionally’ had adequate assistance from support staff. In 82.4% of the 51 ICUs for which data were obtained, the distance between patient beds was adequate in patient-care areas (between 57.7 and 300 cm). In 64.1% of the units, patient transfers were performed using wheeled beds. In 58.2% of the units, transfer aids were not used during manual patient handling, and there was no lifting equipment in any ICU. RULA scores
The observations to determine the ergonomic risk scores of the nurses during patient turning and bending down movements were measured using the RULA form scores and recorded. Each nurse was observed with two separate RULA forms for two positions (patient turning and bending down) during the observation. The nurses were informed that they would be observed in their work environment, but the exact time of this observation was not specified. Bending down scores
The nurses’ mean RULA bending down score A, score B and grand scores were 3.0 ± 0.6 (range: 1–6), 4.2 ± 0.4 (range: 1–7) and 3.9 ± 0.8 (range: 2–7), respectively. The score value of 3.0 shows that the upper and lower arms are positioned in a neutral position, forearm in flexion at a maximal angle of 60° and the wrist at a maximal 15° extension. The mean score B of 4.2 indicates that the head of the nurse is at a normal position in relation to the body but may be bent sideways, the body may be bent forward 20–60° and, on some occasions, the weight distribution is imbalanced because the legs are not supported. The grand RULA score of 3.9 implies that individuals should be evaluated further. Patient turning scores
The nurses’ mean RULA patient turning score A, score B and grand scores were 5.8 ± 1.0 (range: 2–7), 5.8 ± 1.1 (range: 1–7) and 6.5 ± 0.8 (range: 2–7), respectively. The score A value of 5.8 shows that the nurses’ upper and lower arms were moving away from the body at 20–90° and that the wrist is at a maximal 15° extension. The mean score B of 5.8 implies that the head is at a maximal 20° flexion or extension, the body is inclined forward at a maximum of 60° and the legs are at a normal risk score range. The grand mean RULA score of 6.5 indicates the need for further evaluation of the individual and that immediate preventive measures are required for working conditions. MSD symptoms
The prevalence of MSD symptoms for all body regions of the nurses was 95.9%. Pain intensity score (mean) was 5.6 ± 2.2.
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Pain intensity was ≥6 points in 53.3% of the nurses. The prevalence of MSD according to body regions was as follows: legs (64.4%), lower back (58.8%), back (44.6%), shoulders (33.7%), neck (30.3%), feet (14.9%), arms (14.6%), wrist (9.6%) and head (7.4%). In the evaluation of the relationship between prevalence of MSD symptoms and general characteristics and RULA scores, the prevalence of MSD symptoms was higher in nurses with an education level of bachelor’s/master’s (P < 0.05), those who never exercise (P < 0.05), those who define their daily workload as ‘too much’ (P < 0.05), those with ‘irregular’ changes in work schedule (P < 0.05), those who define income satisfaction as ‘not at all’ (P < 0.05) and those who define their general health as ‘very bad’ (P < 0.001) than in others (Table 2). The logistic regression analysis of the risk factors related to MSD symptoms
No factors predictive for the presence of MSD symptoms in the back, shoulder, neck, feet, arms, wrist and head regions could be found. Having leg symptoms
Logistic regression analysis revealed that there are two variables that have significant odds ratios. These are ‘Working on the 08:00–16:00/16:00–08:00 shift’ [odds ratios (OR): 7.93, confidence interval (CI): 1.95–32.17] and ‘Working for 3–10 years in the ICU’ (OR: 3.538, CI: 1.152–10.860) (Table 3). Having lower back symptoms
Statistically significant risk factors are shown in Table 3. ‘Working at a public hospital’ (OR: 1.395, CI: 0.699–2.784), ‘Never doing exercise’ (OR: 1.407, CI: 0.660–3.000) and ‘Working for 11–20 years’ (OR: 1.288, CI: 0.619–2.680) had significant odd ratios. ‘Having irregular changes in work schedule’ had a 0.69 times higher risk than did ‘Having weekly changes in work schedule’ (OR: 0.691, CI: 0.353–1.350). ‘Never having adequate assistance from support staff’ had a 3.5 times higher risk than did ‘Always having adequate assistance from support staff’ (OR: 3.50, CI: 1.111–11.030). ‘Having a RULA score A of over 7 points’ for patient turning movement showed a 7.4 times higher risk than that for ‘Having a RULA score A of less than 7 points’ (OR:7.448, CI:1.568–35.388).
Discussion The results of this study have revealed important findings on MSD symptoms among ICU nurses and factors that affect those symptoms. In addition, the data of this study were obtained using a reliable and valid tool, which was developed to determine ergonomic risks and has been used in other international
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studies. Our findings may be generalized for Turkey inasmuch as our sample is representative of all nurses working in adult ICUs in Istanbul and because the sample was randomly selected. In the Results section of this study, it was showed that ICU nurses have both a high degree of MSDs and high ergonomic risks. The frequency of experiencing an MSD symptom in the previous month was very high, at 95.9%. In addition, the ICU nurses’ pain intensity score (mean) was 5.6 ± 2.2. This result is disappointing for a young study group, who are mostly aged between 21 and 35. The frequency of having an MSD symptom was reported as 76% in a study among nurses from Taiwan (Chung et al. 2013). The frequency of MSD symptoms in nurses in Turkey was 79% in a study by Pınar (2010). When this was compared with the findings of the present study, MSD symptoms seemed to be much more frequent in ICU nurses. The most frequent MSD symptoms were found in the leg, lower back, back, shoulders and neck regions. In studies performed in Italy, Brazil and Estonia to define MSD symptoms in nurses, the most frequent regions were found to be the lower back, neck, knee and ankle (Carugno et al. 2012; Freimann et al. 2013). By contrast, in our study, MSD symptoms were found to be most frequent in the legs. The ergonomic risks of nurses were evaluated with the RULA form and thus their postures during their most frequent movements ‘bending down’ and ‘patient turning’ were observed in terms of ergonomic risk. The movements for turning the patient were found to be riskier than those for bending down. We could not find any other studies that had used RULA to determine the risks for nurses of MSD symptoms. There are significant differences in education, daily workload, changes in work schedule, income satisfaction, frequency of exercise, RULA scores and general health perceptions between MSD symptoms. With regard to MSD symptoms in studies from different countries, a study carried out in Estonia found that nurses there had low back and neck pain more than as often as Swedish nurses (Freimann et al. 2013), and when Italian and Brazilian nurses were compared, it was found that psychosocial and cultural characteristics had an effect on the MSD prevalence (Carugno et al. 2012). The differences in the MSD prevalence among countries could be related to ICU nurses’ workplace characteristics, socio-cultural environments and health systems. In this study, the frequency of MSD symptom was higher in nurses with an educational level of bachelors’ and/or master’s degree. One reason for the significant association between higher educational level and MSD symptoms in the present study may be that nurses continue their active work at the
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Table 2 The relationship between musculoskeletal disorder symptoms and general characteristics, working conditions and Rapid Upper Limb Assessment (RULA) scores (n: 323)
Independent variables (n)
Musculoskeletal Symptoms Yes (n: 310)%
Gender Female (256) Male (67) Education High school/Vocational (147) Bachelor or master degree (176) Cigarette smoking Yes (89) No (233) Frequency of exercise Never (280) At least three times a week (43) General health perceptions Very bad (17) Moderate (169) Good (128) Very good (9) Type of hospital Private hospital (77) Public hospital (184) University hospital (62) Type of shift work Type 1 (08–16/16–08) (129) Type 2 (08–20/20–08) (129) Type 3 (08–18/18–08) (65) Daily workload Not much (1) Somewhat (12) Reasonable (180) Too much (128) Frequency of changes in working order Weekly (10) Monthly (59) Irregular (250) Total years in nursing 0–2 years (73) 3–10 years (196) 11–20 years (54) Total years in ICU nursing 0–2 years (158) 3–10 years (150) 11–20 years (15) Daily working time Less than 12 h (193) More than 12 h (130)
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Statistics
Significant
No (n: 13)%
96.5 94.0
3.5 6.0
χ2 = 0.828; d.f. = 1
P = 0.363
93.2 98.3
6.8 1.7
χ2 = 5.390; d.f. = 1
P = 0.020*
94.4 96.6
5.6 3.4
χ2 = 0.793; d.f. = 1
P = 0.373
88.4 97.1
11.6 2.9
χ2 = 7.423; d.f. = 1
P = 0.006*
100.0 98.8 95.3 44.4
0.0 1.2 4.7 55.6
χ2 = 66.260; d.f. = 4
P = 0.001**
94.8 96.2 96.8
5.2 3.8 3.2
χ2 = 0.398; d.f. = 2
P = 0.819
95.3 97.7 93.8
4.7 2.3 6.2
χ2 = 1.858; d.f. = 2
P = 0.395
100.0 75.0 96.1 97.7
0.0 25.0 3.9 2.3
χ2 = 14.738; d.f. = 4
P = 0.005*
80.0 96.6 96.4
20.0 3.4 3.6
χ2 = 6.673; d.f. = 2
P = 0.036*
94.5 97.4 92.6
5.5 2.6 7.4
χ2 = 3.102; d.f. = 2
P = 0.212
95.6 96.0 100.0
4.4 4.0 0.0
χ2 = 0.697; d.f. = 2
P = 0.706
95.3 96.9
4.7 3.1
χ2 = 0.506; d.f. = 1
P = 0.477
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Table 2 Continued
Independent variables (n)
Musculoskeletal Symptoms Yes (n: 310)%
Weekly working time Less than 40 h (99) More than 12 h (224) Income satisfaction Not at all (82) Somewhat (191) Satisfied (46) RULA bending down score A Between 1 and 3 (265) Between 4 and 6 (58) RULA bending down score B Between 1 and 3 (81) Between 4 and 6 (224) 7 and above (18) RULA bending down grand score Between 1 and 2 (1) Between 3 and 4 (15) Between 5 and 6 (96) 7 and above (210) RULA patient turning score A Between 1 and 3 (10) Between 4 and 6 (227) 7 and above (86) RULA patient turning score B Between 1 and 3 (11) Between 4 and 6 (193) 7 and above (119) RULA patient turning grand score Between 1 and 2 (1) Between 3 and 4 (15) Between 5 and 6 (96) 7 and above (210)
Statistics
Significant
χ2 = 1.890; d.f. = 3
P = 0.595
χ2 = 6.420; d.f. = 2
P = 0.040*
No (n: 13)%
93.9
6.1
96.7 97.6 96.9 89.1
3.3 2.4 3.1 10.9
95.5 98.3
2.5 1.7
χ2 = 0.969; d.f. = 1
P = 0.325
97.5 95.1 100.0
2.5 4.9 0.0
χ2 = 1.717; d.f. = 2
P = 0.424
100.0 95.2 100.0 100.0
0.0 4.8 0.0 0.0
χ2 = 2.719; d.f. = 3
P = 0.437
90.0 96.5 95.3
10.0 3.5 4.7
χ2 = 1.159; d.f. = 2
P = 0.560
100.0 95.3 96.6
0.0 4.7 3.4
χ2 = 0.801; d.f. = 2
P = 0.670
100.0 93.3 94.8 96.7
0.0 6.7 5.2 3.3
χ2 = 0.918; d.f. = 3
P = 0.821
*P < 0.05; **P < 0.001.
hospital while they also continue their bachelor’s/master’s degree education. This situation may cause excessive fatigue in nurses, which may result in higher frequency of MSD symptoms. The findings of the present study, in line with similar studies, show that psychosocial factors and work conditions were found to be associated with the presence of MSD symptoms. Occupational lower back pain was found to be associated with the daily workload of the institution and income satisfaction (Dündar et al. 2010).
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In developing countries, nurses immigrate to European, Northern and other wealthy countries to work in better conditions and to earn an increased income. This migration leads to the problem of inadequate staffing in developing countries. Having MSD symptoms affects the cost of nursing and has significant social effects inasmuch as MSD symptoms cause sick leave and absenteeism among nurses (Harcombe et al. 2009; Tinubu et al. 2010). Nurse shortages are significant for MSD prevalence. In Uganda, there are six nurses per 100 000 people, there are 236
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Table 3 Logistic regression analysis of musculoskeletal disorder symptoms among body parts According to body parts having musculoskeletal symptoms
Variables (%)
Having leg symptoms (n = 208)
Type of shift work (with symptom %) 08–18/18–08 (16.3) 08–16/16–08 (42.8) 08–20/20–08 (40.9) Total years in nursing (with symptom %) Working 0–2 years (23.6) Working 3–10 years (62.0) Working 11–20 years (14.4) Type of hospital (with symptom %) Private hospital (22.1) Public hospital (63.2) University hospital (14.7) Frequency of exercise (with symptom %) At least three times a week (15.8) Never (84.2) Total years in nursing (with symptom %) 0–2 years (17.9) 3–10 years (64.7) 11–20 years (17.4) Frequency of changes in working order (with symptom %) Weekly (1.6) Monthly (17.1) Irregular (81.3) To have adequate assistance from support staff (with symptom %) Always (30.6) Often (50.0) Occasionally (14.7) Never (4.7) RULA patient turning score A (with symptom %) Between 1 and 3 (1.6) Between 4 and 6 (70.0) 7 and above (28.4)
Having lower back symptoms (n = 190)
Unadjusted OR
95% CI
1.00 7.938 3.357
1.958–32.178 0.300–37.624
1.00 3.538 3.134
1.152–10.860 1.255–7.827
1.00 1.395 0.422
0.699–2.784 0.188–0.947
1.00 1.407
0.660–3.000
1.00 0.536 1.288
0.234–1.228 0.619–2.680
1.00 0.144 0.691
0.032–0.647 0.353–1.350
1.00 1.619 2.850 3.500
0.517–5.075 0.793–10.246 1.111–11.030
1.00 6.275 7.448
1.401–28.113 1.568–35.388
95% CI, 95% confidence interval; OR, odds ratio; RULA, Rapid Upper Limb Assessment.
nurses per 100 000 people in Turkey, and 736 nurses per 100 000 people in the WHO European Region (Munabi et al. 2014; World Health Organization (WHO) 2013). In Turkey, there are some new regulations to increase numbers of students and academic staff in nursing schools to prevent nurse shortages. In order to prevent absenteeism due to MSDs, it is necessary to have enough nurses in clinics who are well educated and qualified. Smoking and absence of regular exercise have been reported as increasing the risk level of MSD injuries in previous studies (Long et al. 2012). A significant association between smoking
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habit and MSD symptom occurrence was not detected in this investigation. However, the high prevalence of MSD symptoms among persons who described their health status as ‘poor’ or ‘very poor’ suggests that this might have been expected. In the literature, there are studies on prevention of ergonomic risks for nurses and health promotion among them. These studies and systematic reviews evaluate the effects of interventions such as back schools, ergonomic training, antismoking education and exercise programmes intended to reduce work-related MSDs. Studies report that multiple interventions could produce more significant outcomes which
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suggest participatory ergonomic interventions, engineering and administrative controls. (Black et al. 2011; Côté et al. 2013; Lim et al. 2011). In the countries that have nurse shortages, low resources and low income, there are more MSDs. Given these circumstances, it might be that organizational factors have significant effects on the prevalence of MSD (Munabi et al. 2014). In the present study, most of the predictors for MSD symptoms in the low back and leg regions of the ICU nurses were the result of organizational factors such as type of hospital, type of shift work, frequency of changes in work schedule and inadequate assistance from support staff. There are transfer aids and lifts that are used to decrease the ergonomic risks in patient-care environments. There were no transfer aids or lifts in this study, which was conducted in 51 ICUs. Studies show that in low-resource settings, nurses do not have transfer aids to use during manual patient handling (Munabi et al. 2014). With regard to the situation in the USA, European countries and some Asia-Pacific countries, previous studies have found that lifts were effective tools during the manual handling of patients. Despite that, even in units where lifts are present, their use may be inadequate because of the time loss involved and the difficulty in their use (Lee et al. 2013). As expected by the researchers, the RULA scores indicated that ICU nurses’ postures needed to be investigated and changed immediately. Ergonomic programmes for healthcare workers should include periodic and systematic activities to determine the risks in the workplace. Also, this process requires direct communication with workers. Nevertheless, how can these services be provided in developing countries or those without sufficient occupational health services? A law in Turkey related to workers’ health came into force in 2012 but has not been implemented yet (Ministry of Labour and Social Security (MLSS) 2012). Therefore, this problem could be solved by developing occupational health units in hospitals and employing trained occupational health nurses urgently. These nurses are able to analyse the risks for healthcare workers by interacting with them in their workplace (Esin et al. 2008). With the aim of increasing awareness of the issue, occupational health practices should be included in the nursing curriculum. Besides modern and interactive undergraduate/postgraduate courses, service training could be organized for staff nurses. In addition, cooperation with national and international civil society organizations could be organized. As with every study, this study has some limitations: although a representative sample was used in the study, the administrators of the hospitals in which the study was carried out gave permission for only one observation per nurse by a single researcher. To have more reliable data, ICU nurses should be
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observed in the same position at least twice, allowing for a mean score for observations.
Conclusions This study has revealed the prevalence of MSD symptoms due to working conditions and variables that had an effect on such symptoms among ICU nurses. The main factors in the occurrence of MSD symptoms were found to be associated with risks stemming from the institution. The need for institutional organization aimed at reducing the frequency of MSD is shown in multiple studies. In this context, the personal characteristics of nurses are found to be less important than institutional features in the occurrence of MSD. The study sample is representative of all adult ICUs in Turkey, and this study is one of the first studies that used a reliable tool in data acquisition to focus on a specific area in nursing practice, namely determining ICU nurses’ ergonomic risks.
Implications for nursing and health policy The findings of this study may be used in programmes intended at prevention of musculoskeletal systems among healthcare professionals by nurses and physicians providing information on occupational health. Health policy makers should develop occupational health units in all hospitals to prevent nurses’ and other health professionals’ health problems by creating a healthy work environment. In these units, ‘ergonomic risk prevention programmes’ should be implemented by occupational health teams in which expert occupational health nurses take part. At this point, occupational health nursing education can be re-checked in the countries such as Turkey.
Acknowledgements We thank all public, university and private hospital’s administrations that gave permission to collect data for this study.
Author contributions Study conception/design: Duygu Sezgin and M. Nihal Esin. Data collection/analysis: Duygu Sezgin. Drafting of manuscript: Duygu Sezgin and M. Nihal Esin. Critical revisions for important intellectual content: M. Nihal Esin. Supervision: M. Nihal Esin. Statistical expertise: M. Nihal Esin. Administrative/ technical/material support: Duygu Sezgin and M. Nihal Esin.
References American Association of Critical Care Nurses (AACN) (2013) Standards of Practice. Available at: http://www.aacn.org/wd/practice/docs/standardsof-practice-public-comment.pdf (accessed 11 June 2014).
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Black, T.R., et al. (2011) Effect of transfer, lifting, and repositioning (TLR) injury prevention program on musculoskeletal injury among direct care workers. Journal of Occupational and Environmental Hygiene, 8 (4), 226– 235. Carugno, M., et al. (2012) Physical and psychosocial risk factors for musculoskeletal disorders in Brazilian and Italian nurses. Cadernos de Saúde Pública, 28 (9), 1632–1642. Chung, Y.C., et al. (2013) Risk of musculoskeletal disorder among Taiwanese nurses cohort: a nationwide population-based study. BMC Musculoskeletal Disorders, 14 (1), 144. Côté, J.N., et al. (2013) Quebec research on work-related musculoskeletal disorders: deeper understanding for better prevention. Industrial Relations, 68 (4), 643–660. DeCastro, A.B., et al. (2010) Associations between work schedule characteristics and occupational injury and illness. International Nursing Review, 57 (2), 188–194. Dündar, P.E., et al. (2010) Low back pain and related factors in nurses in a university hospital. Turkish Journal of Public Health, 8 (2), 95–104. Esin, M.N., Emirog˘lu, O.N., Aksayan, S. & Bes¸er, A. (2008) Undergraduate occupational health nursing education in Turkey: a national survey. International Nursing Review, 55 (2), 156–163. European Foundation for the Improvement of Living and Working Conditions (EFILWC) (2010) European Working Conditions Surveys. Available at: http://www.eurofound.europa.eu/pubdocs/2010/74/tr/1/EF1074TR .pdf (in Turkish) (accessed 17 December 2011). Freimann, T., et al. (2013) Risk factors for musculoskeletal pain amongst nurses in Estonia: a cross-sectional study. BMC Musculoskeletal Disorders, 14 (1), 334. Harcombe, H., McBride, D., Derrett, S. & Gray, A. (2009) Prevalence and impact of musculoskeletal disorders in New Zealand nurses, postal workers and office workers. Australian and New Zealand Journal of Public Health, 33 (5), 437–441. I˙lçe, A. & Dramalı, A. (2010) Investigation of intensive care units’ characteristics related to ergonomic factors. Journal of Research and Development in Nursing, 1, 53–63. (In Turkish.) Lee, S.J., Faucett, J., Gillen, M. & Krause, N. (2013) Musculoskeletal pain among critical-care nurses by availability and use of patient lifting equipment: an analysis of cross-sectional survey data. International Journal of Nursing Studies, 50 (12), 1648–1657.
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Lemo, A., et al. (2012) Risk reduction in musculoskeletal practice assistance professional nursing pilot in semi intensive care unit. Work (Reading, Mass.), 41, 1869–1872. Lim, H.J., et al. (2011) Evaluating repeated patient handling injuries following the implementation of a multi-factor ergonomic intervention program among health care workers. Journal of Safety Research, 42 (3), 185–191. Long, M.H., Johnston, V. & Bogossian, F. (2012) Work-related upper quadrant musculoskeletal disorders in midwives, nurses and physicians: a systematic review of risk factors and functional consequences. Applied Ergonomics, 43 (3), 455–467. McAtamney, L. & Nigel Corlett, E. (1993) RULA: a survey method for the investigation of work-related upper limb disorders. Applied Ergonomics, 24 (2), 91–99. Ministry of Labour and Social Security (MLSS) (2012) Occupational Health and Safety Law. No: 6331. Available at: http://www.resmigazete.gov.tr/ eskiler/2012/06/20120630-1.htm (in Turkish) (accessed 6 September 2014). Munabi, I.G., et al. (2014) Musculoskeletal disorder risk factors among nursing professionals in low resource settings: a cross-sectional study in Uganda. BMC Nursing, 13 (1), 7. Öztürk, N. & Esin, M.N. (2007) Determining ergonomic risks: introduction of rapid upper risk assessment form. Turkish Physicians Association Journal of Occupational Health and Safety, 30, 31–37. (In Turkish.) Öztürk, N. & Esin, M.N. (2011) Investigation of musculoskeletal symptoms and ergonomic risk factors among female sewing machine operators in Turkey. International Journal of Industrial Ergonomics, 41 (6), 585–591. Pınar, R. (2010) Work-related musculoskeletal disorders in Turkish hospital nurses. Turkish Clinics Journal of Medical Sciences, 30 (6), 1869– 1875. Tinubu, B.M.S., Mbada, C.E., Oyeyemi, A.L. & Fabunmi, A.A. (2010) Work-related musculoskeletal disorders among nurses in Ibadan, southwest Nigeria: a cross-sectional survey. BMC Musculoskeletal Disorders, 11 (1), 12. Tullar, J.M., et al. (2010) Occupational safety and health interventions to reduce musculoskeletal symptoms in the health care sector. Journal of Occupational Rehabilitation, 20 (2), 199–219. World Health Organization (WHO) (2013) Health for All Database 2013. Available at: http://data.euro.who.int/hfadb/ (accessed 2 February 2014).
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Nursing Work and Life
Predisposing factors for musculoskeletal symptoms in intensive care unit nurses D. Sezgin1
MSc
& M.N. Esin2 PhD
1 Lecturer, Nursing Department, Faculty of Health Sciences, Bezmialem Vakif University, 2 Associate Professor, Public Health Nursing Department, Faculty of Nursing, Istanbul University, Istanbul, Turkey
SEZGIN D. & ESIN M.N. (2015) Predisposing factors for musculoskeletal symptoms in intensive care unit nurses. International Nursing Review 62, 92–101 Introduction: Intensive care unit nurses have more ergonomic risks than nurses working in other units in hospital. Background: Although musculoskeletal disorders are common among intensive care nurses, studies on the prevalence of symptoms, as well as associated factors, are scarce. Aim: This is a cross-sectional study to investigate the prevalence of musculoskeletal symptoms and associated factors in intensive care nurses. Methods: The study population comprised 1515 nurses working in the intensive care units of public, private and university hospitals in Turkey. The study sample included 323 nurses selected by stratified random sampling. Data were obtained by a tailored data collection form, a workplace observation form and a Rapid Upper Limb Assessment tool to delineate ergonomic risks. Statistical Package for the Social Sciences 21.0 software was used in the statistical analysis. Results: The highest prevalence for the musculoskeletal symptoms of the nurses was in the legs, lower back and back. Most of the nurses had encountered musculoskeletal pain or discomfort related to the previous month. The risky body movements that were frequently performed by the nurses during a shift were ‘turning the patient’ and ‘bending down’. Discussion: The final Rapid Upper Limb Assessment score for the patient turning movement was found to be higher than for the bending down movement. Conclusions: Musculoskeletal symptoms, which may occur in any region of the body, are mainly associated with organizational factors, such as type of hospital, type of shift work and frequency of changes in work schedule, rather than with personal factors. Implications for Nursing and Health Policy: Nursing administrators should determine the ergonomic risks of intensive care unit nurses by using Rapid Upper Limb Assessment tool. Health policy makers should develop occupational health teams, and ‘ergonomic risk prevention programs’ should be implemented throughout the units.
Correspondence address: Melek Nihal Esin, Public Health Nursing Department, Faculty of Nursing, Istanbul University, Abide-i Hurriyet Caddesi, Istanbul 34381, Turkey; Tel: +90-212-224-49-86; Fax: +90-212-224-49-90; E-mail: [email protected].
Funding source This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. Financial costs were covered by the researchers. Conflict of interest No conflict of interest has been declared by the authors.
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Keywords: Ergonomic Risks, Intensive Care Nurse, Musculoskeletal System, Nursing injuries, Back injuries, Rapid Upper Limb Assessment, Occupational Health
Introduction Musculoskeletal disorders (MSDs) are the most common health problems in all work-related disabilities and injuries. Two factors are important in the development of occupational MSDs, namely ‘repetitive strain’ and ‘cumulative trauma’. In the long term, muscle, bone or tendon injuries may occur or develop as a result of acute excessive straining (Côté et al. 2013; Tullar et al. 2010). Nurses repeat movements such as pushing, pulling, elevating and bending too much in their work environment, as a result of which, MSDs may easily develop (Lee et al. 2013; Long et al. 2012). The main injuries affect the cervical level, the lower cervical spine, the thoracic spine, the thoracolumbar junction, and the lumbar and sacral vertebrae (Chung et al. 2013; I˙lçe & Dramalı 2010). Intensive care units (ICUs) are identified as having the highest occupational risk in terms of ergonomic risk (American Association of Critical Care Nurses (AACN) 2013; Black et al. 2011). MSD development in ICU nurses is caused by physical and psychosocial factors, such as standing for long hours, daily workload, working in shifts, dissatisfaction with work, caring for patients with co-morbidities, frequently encountered deaths, interaction with families of patients and inadequate income (American Association of Critical Care Nurses (AACN) 2013; DeCastro et al. 2010; European Foundation for the Improvement of Living and Working Conditions (EFILWC) 2010; Lemo et al. 2012). In addition, personal factors, such as ageing, inadequate physical condition, smoking and obesity, are important in the development of MSDs (Black et al. 2011; Tullar et al. 2010). Generally, ICU nurses have more risks than nurses working in other hospital units (Pınar 2010).
Background The prevalence of musculoskeletal injuries in nurses and other healthcare professionals due to patient handling tasks was found to be between 40% and 84% in developing and developed countries (Carugno et al. 2012; Chung et al. 2013; Freimann et al. 2013; Harcombe et al. 2009; Munabi et al. 2014; Tinubu et al. 2010). The frequency of musculoskeletal symptoms in the previous 12 months were found to be 80.8% and 78.0%, respectively, in sub-Saharan African countries such as Uganda and Nigeria (Munabi et al. 2014; Tinubu et al. 2010). The prevalence of musculoskeletal pain reported in the previous
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month was 69.0% in Estonian nurses, and 76.24% of the nurses working at hospitals in Taiwan had musculoskeletal injuries (Chung et al. 2013; Freimann et al. 2013). In the studies performed on nurses from Italy, Brazil and New Zealand, the prevalence of MSDs were found to be 49.1%, 45.1% and 40.0%, respectively (Carugno et al. 2012; Harcombe et al. 2009). In Turkey, the prevalence of MSD symptoms in nurses was found to be 79.5% in hospital nurses, and ICU nurses were found to be more likely to suffer from MSDs than other nurses (Pınar 2010). Studies investigating the ergonomic risks, MSDs and related factors in ICU nurses are scarce, however, and generally depend upon self-reporting and determination of MSDs in regions such as lower back, shoulders and back (Black et al. 2011). Ergonomic risks that have the most significant impact on MSD development should be determined with valid and reliable measurement tools. Studies in which such tools are used are also scarce. The Rapid Upper Limb Assessment (RULA), which was used to obtain the data in this study, is a reliable tool extensively used by investigators in measuring ergonomic risks.
Aim This study was conducted to determine the prevalence of musculoskeletal symptoms in ICU nurses and to delineate their risk factors. The questions to which we intended to find answers were as follows: • What is the prevalence of MSD among ICU nurses, according to answers obtained with a tailored data collection form? • What are the ergonomic workplace risk factors among ICU nurses, according to data obtained with RULA? • What are the predisposing risk factors for MSD development in ICU nurses?
Methods Setting
This cross-sectional study was organized in hospitals in the European and Asian parts of Istanbul, which is a cosmopolitan, densely populated and economically rich city in northwestern Turkey. Many patients from other regions of Turkey, and lately from other countries as well, come to Istanbul. There were 281 hospitals (public, private and university hospitals) in Istanbul during the period when this study was conducted. Data for this study were obtained from 51 adult ICUs (general, coronary, car-
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diovascular surgery and reanimation) in 17 hospitals, where ergonomic risks such as weight-lifting are considered to be high. Sample
A total of 1515 nurses work at these 51 ICUs. The sample size was calculated by the formula n = Nt2pq/d2(N − 1) + t2pq (t:1.96, d:0.05, P = 50%, q = 1 − p), yielding 306 nurses. When data loss was taken into consideration, the final sample size was set at 350 nurses. The nurses were selected by stratified random sampling. As the working conditions of the strata are different, the nurses were stratified according to public, private and university hospitals. The procedure was to select a sample randomly from each stratum that was proportional to the stratum’s size in relation to the population. The strata weights and the number of nurses from each strata are shown in Table 1. Sample selection was performed using a simple random sampling method. The lists of nurses working at each hospital were obtained from the respective hospitals. Thirty-three ICU nurses from the first stratum and one ICU nurse from the second stratum could not be reached during the study. All the nurses intended for selection from the third stratum were reached, and an additional seven nurses were included in the sample. Thus, 323 ICU nurses comprised the sample. Data collection methods
The data were collected during the period between 8 February and 20 March 2012 by observation and personal interviews. Tailored data collection form
The form was constructed in accordance with the Nordic Musculoskeletal Questionnaire, which was developed by McAtamney & Nigel Corlett (1993). It consisted of five sections. The first section included questions on demographic characteristics: gender, education, age, marital status and living with children; the second included questions on working conditions: type of hospital/ICU, daily workload, type of shift work, frequency of changes in work schedule, total years in nursing/ICU nursing, daily/weekly working time; the third included ques-
tions on psychosocial characteristics: income and work satisfaction, relationships with colleagues and managers, feelings of being under pressure due to work; the fourth section included questions on ergonomic risks: ergonomic training programmes, frequency of exercise, lifting weights outside of working hours, adequate assistance from support staff; the last section included questions on general health status: cigarette smoking, general health perceptions, MSD symptoms, diagnosed MSDs and intensity of pain. The nurses were requested to specify, on a body discomfort chart, the regions where they had felt any symptoms of MSD in the preceding month. They were also asked to score the intensity of pain on a visual analogue scale. Work environment evaluation observation form
This form was developed by the investigators, based upon the relevant literature, in order to evaluate the physical and ergonomic appropriateness of the workplace environment of ICU nurses. Criteria such as patient transfers done by stretcher or patient bed, presence of a sufficient area for bedside support units and presence of lifts for patient transfer were included in the observation form. RULA
Data on the ergonomic risk factors of nurses were obtained by direct observation using the Rapid Upper Limb Assessment (RULA), which is a validated tool used to diagnose work-related upper limb disorders, biometrical and postural loading (McAtamney & Nigel Corlett 1993). The Turkish validation of RULA was performed in 2007 (Öztürk & Esin 2007). When RULA is used, calculations are made in relation to the posture of the various body parts. Score A combines the scores relating to the two limbs as well as the wrist scores. The scores relating to neck, trunk as well as legs are covered in score B. A score of 1 or 0 relates to the positioning of the muscles in use or force that is exerted to the same when they are in a working situation. When 1 and 0 scores are added to A and B scores, the result obtained is C and D scores. The grand scores are arrived at by summing the C and D scores. Low grand scores
Table 1 Number of selected nurses with stratified random sampling Stratum No.
Hospital type (number)
Number of nurses
Strata weights
Number of nurses to be selected
Number of selected nurses
1 2 3 Total
Public hospital (9) University hospital (2) Private hospital (6) 17
950 265 300 1515
950/1515 = 0.62 265/1515 = 0.18 300/1515 = 0.20 1.00
0.62 × 350 = 217 0.18 × 350 = 63 0.20 × 350 = 70 350
184 62 77 323
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(1 or 2) show the ‘acceptable’ work posture. It is recommended that action be taken in cases of higher scores. For grand scores of 3 or 4, further analyses may be recommended and modifications to improve the score should be made if required. Immediate analyses and modifications are suggested for grand scores of 5 or 6. Also, analyses and modifications should be performed promptly for a grand score of 7 (McAtamney & Nigel Corlett 1993; Öztürk & Esin 2007, 2011). Data analysis
Statistical Package for the Social Sciences version 21.0 software, licenced to Istanbul University (IBM Corp., Armonk, NY, USA), was used in the analysis of the data. The general characteristics and ergonomic risks of the nurses were displayed as number, percentage and mean. Chi-square test and logistic regression analysis were used in the evaluation of the association between these characteristics and MSD symptoms. Estimation was made at odds ratios and at a degree of confidence of 95% to find out the risks and prevalence of musculoskeletal symptoms in unadjusted logistic regression models. Ethical issues
Ethical approval was obtained from the Ethics Committee of Istanbul University Institute of Cardiology before initiating the study (Protocol No. 2012/02). All of the nurses signed informed consent forms.
Results General characteristics
Of the nurses participating in this study, 79.3% were female and 48.3% had a bachelor’s degree, whereas 60.4% were single, 86.7% were aged between 21 and 35 years (mean age 27.9 ± 5.1) and 76.8% were ‘not living with children’. A past diagnosis of MSD was present in 18.3% of the nurses. The most frequent MSD was defined as ‘spinal diseases’. Work and workplace characteristics
Weekly total work duration was (mean) 47.2 ± 8.9 h; 32.8% of the nurses were working at a cardiovascular surgery ICU. Total years in nursing (mean) were 6.4 ± 4.9 years and the total duration of standing in a shift was 8.2 ± 1.9 h. Of the nurses, 71.8% could have breaks during the day, and the duration of work until a break was 5.9 ± 2.8 h. Whereas 65.3% defined their relationships with colleagues and managers as ‘reasonable’, 38.1% ‘occasionally’ felt pressured by work. Of the nurses, 80.2% reported not attending an ergonomic training programme at their institution at any time. Whereas
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40.2% of the nurses reported ‘occasionally’ lifting weights outside of working hours, 44.9% ‘occasionally’ had adequate assistance from support staff. In 82.4% of the 51 ICUs for which data were obtained, the distance between patient beds was adequate in patient-care areas (between 57.7 and 300 cm). In 64.1% of the units, patient transfers were performed using wheeled beds. In 58.2% of the units, transfer aids were not used during manual patient handling, and there was no lifting equipment in any ICU. RULA scores
The observations to determine the ergonomic risk scores of the nurses during patient turning and bending down movements were measured using the RULA form scores and recorded. Each nurse was observed with two separate RULA forms for two positions (patient turning and bending down) during the observation. The nurses were informed that they would be observed in their work environment, but the exact time of this observation was not specified. Bending down scores
The nurses’ mean RULA bending down score A, score B and grand scores were 3.0 ± 0.6 (range: 1–6), 4.2 ± 0.4 (range: 1–7) and 3.9 ± 0.8 (range: 2–7), respectively. The score value of 3.0 shows that the upper and lower arms are positioned in a neutral position, forearm in flexion at a maximal angle of 60° and the wrist at a maximal 15° extension. The mean score B of 4.2 indicates that the head of the nurse is at a normal position in relation to the body but may be bent sideways, the body may be bent forward 20–60° and, on some occasions, the weight distribution is imbalanced because the legs are not supported. The grand RULA score of 3.9 implies that individuals should be evaluated further. Patient turning scores
The nurses’ mean RULA patient turning score A, score B and grand scores were 5.8 ± 1.0 (range: 2–7), 5.8 ± 1.1 (range: 1–7) and 6.5 ± 0.8 (range: 2–7), respectively. The score A value of 5.8 shows that the nurses’ upper and lower arms were moving away from the body at 20–90° and that the wrist is at a maximal 15° extension. The mean score B of 5.8 implies that the head is at a maximal 20° flexion or extension, the body is inclined forward at a maximum of 60° and the legs are at a normal risk score range. The grand mean RULA score of 6.5 indicates the need for further evaluation of the individual and that immediate preventive measures are required for working conditions. MSD symptoms
The prevalence of MSD symptoms for all body regions of the nurses was 95.9%. Pain intensity score (mean) was 5.6 ± 2.2.
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Pain intensity was ≥6 points in 53.3% of the nurses. The prevalence of MSD according to body regions was as follows: legs (64.4%), lower back (58.8%), back (44.6%), shoulders (33.7%), neck (30.3%), feet (14.9%), arms (14.6%), wrist (9.6%) and head (7.4%). In the evaluation of the relationship between prevalence of MSD symptoms and general characteristics and RULA scores, the prevalence of MSD symptoms was higher in nurses with an education level of bachelor’s/master’s (P < 0.05), those who never exercise (P < 0.05), those who define their daily workload as ‘too much’ (P < 0.05), those with ‘irregular’ changes in work schedule (P < 0.05), those who define income satisfaction as ‘not at all’ (P < 0.05) and those who define their general health as ‘very bad’ (P < 0.001) than in others (Table 2). The logistic regression analysis of the risk factors related to MSD symptoms
No factors predictive for the presence of MSD symptoms in the back, shoulder, neck, feet, arms, wrist and head regions could be found. Having leg symptoms
Logistic regression analysis revealed that there are two variables that have significant odds ratios. These are ‘Working on the 08:00–16:00/16:00–08:00 shift’ [odds ratios (OR): 7.93, confidence interval (CI): 1.95–32.17] and ‘Working for 3–10 years in the ICU’ (OR: 3.538, CI: 1.152–10.860) (Table 3). Having lower back symptoms
Statistically significant risk factors are shown in Table 3. ‘Working at a public hospital’ (OR: 1.395, CI: 0.699–2.784), ‘Never doing exercise’ (OR: 1.407, CI: 0.660–3.000) and ‘Working for 11–20 years’ (OR: 1.288, CI: 0.619–2.680) had significant odd ratios. ‘Having irregular changes in work schedule’ had a 0.69 times higher risk than did ‘Having weekly changes in work schedule’ (OR: 0.691, CI: 0.353–1.350). ‘Never having adequate assistance from support staff’ had a 3.5 times higher risk than did ‘Always having adequate assistance from support staff’ (OR: 3.50, CI: 1.111–11.030). ‘Having a RULA score A of over 7 points’ for patient turning movement showed a 7.4 times higher risk than that for ‘Having a RULA score A of less than 7 points’ (OR:7.448, CI:1.568–35.388).
Discussion The results of this study have revealed important findings on MSD symptoms among ICU nurses and factors that affect those symptoms. In addition, the data of this study were obtained using a reliable and valid tool, which was developed to determine ergonomic risks and has been used in other international
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studies. Our findings may be generalized for Turkey inasmuch as our sample is representative of all nurses working in adult ICUs in Istanbul and because the sample was randomly selected. In the Results section of this study, it was showed that ICU nurses have both a high degree of MSDs and high ergonomic risks. The frequency of experiencing an MSD symptom in the previous month was very high, at 95.9%. In addition, the ICU nurses’ pain intensity score (mean) was 5.6 ± 2.2. This result is disappointing for a young study group, who are mostly aged between 21 and 35. The frequency of having an MSD symptom was reported as 76% in a study among nurses from Taiwan (Chung et al. 2013). The frequency of MSD symptoms in nurses in Turkey was 79% in a study by Pınar (2010). When this was compared with the findings of the present study, MSD symptoms seemed to be much more frequent in ICU nurses. The most frequent MSD symptoms were found in the leg, lower back, back, shoulders and neck regions. In studies performed in Italy, Brazil and Estonia to define MSD symptoms in nurses, the most frequent regions were found to be the lower back, neck, knee and ankle (Carugno et al. 2012; Freimann et al. 2013). By contrast, in our study, MSD symptoms were found to be most frequent in the legs. The ergonomic risks of nurses were evaluated with the RULA form and thus their postures during their most frequent movements ‘bending down’ and ‘patient turning’ were observed in terms of ergonomic risk. The movements for turning the patient were found to be riskier than those for bending down. We could not find any other studies that had used RULA to determine the risks for nurses of MSD symptoms. There are significant differences in education, daily workload, changes in work schedule, income satisfaction, frequency of exercise, RULA scores and general health perceptions between MSD symptoms. With regard to MSD symptoms in studies from different countries, a study carried out in Estonia found that nurses there had low back and neck pain more than as often as Swedish nurses (Freimann et al. 2013), and when Italian and Brazilian nurses were compared, it was found that psychosocial and cultural characteristics had an effect on the MSD prevalence (Carugno et al. 2012). The differences in the MSD prevalence among countries could be related to ICU nurses’ workplace characteristics, socio-cultural environments and health systems. In this study, the frequency of MSD symptom was higher in nurses with an educational level of bachelors’ and/or master’s degree. One reason for the significant association between higher educational level and MSD symptoms in the present study may be that nurses continue their active work at the
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Table 2 The relationship between musculoskeletal disorder symptoms and general characteristics, working conditions and Rapid Upper Limb Assessment (RULA) scores (n: 323)
Independent variables (n)
Musculoskeletal Symptoms Yes (n: 310)%
Gender Female (256) Male (67) Education High school/Vocational (147) Bachelor or master degree (176) Cigarette smoking Yes (89) No (233) Frequency of exercise Never (280) At least three times a week (43) General health perceptions Very bad (17) Moderate (169) Good (128) Very good (9) Type of hospital Private hospital (77) Public hospital (184) University hospital (62) Type of shift work Type 1 (08–16/16–08) (129) Type 2 (08–20/20–08) (129) Type 3 (08–18/18–08) (65) Daily workload Not much (1) Somewhat (12) Reasonable (180) Too much (128) Frequency of changes in working order Weekly (10) Monthly (59) Irregular (250) Total years in nursing 0–2 years (73) 3–10 years (196) 11–20 years (54) Total years in ICU nursing 0–2 years (158) 3–10 years (150) 11–20 years (15) Daily working time Less than 12 h (193) More than 12 h (130)
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Statistics
Significant
No (n: 13)%
96.5 94.0
3.5 6.0
χ2 = 0.828; d.f. = 1
P = 0.363
93.2 98.3
6.8 1.7
χ2 = 5.390; d.f. = 1
P = 0.020*
94.4 96.6
5.6 3.4
χ2 = 0.793; d.f. = 1
P = 0.373
88.4 97.1
11.6 2.9
χ2 = 7.423; d.f. = 1
P = 0.006*
100.0 98.8 95.3 44.4
0.0 1.2 4.7 55.6
χ2 = 66.260; d.f. = 4
P = 0.001**
94.8 96.2 96.8
5.2 3.8 3.2
χ2 = 0.398; d.f. = 2
P = 0.819
95.3 97.7 93.8
4.7 2.3 6.2
χ2 = 1.858; d.f. = 2
P = 0.395
100.0 75.0 96.1 97.7
0.0 25.0 3.9 2.3
χ2 = 14.738; d.f. = 4
P = 0.005*
80.0 96.6 96.4
20.0 3.4 3.6
χ2 = 6.673; d.f. = 2
P = 0.036*
94.5 97.4 92.6
5.5 2.6 7.4
χ2 = 3.102; d.f. = 2
P = 0.212
95.6 96.0 100.0
4.4 4.0 0.0
χ2 = 0.697; d.f. = 2
P = 0.706
95.3 96.9
4.7 3.1
χ2 = 0.506; d.f. = 1
P = 0.477
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Table 2 Continued
Independent variables (n)
Musculoskeletal Symptoms Yes (n: 310)%
Weekly working time Less than 40 h (99) More than 12 h (224) Income satisfaction Not at all (82) Somewhat (191) Satisfied (46) RULA bending down score A Between 1 and 3 (265) Between 4 and 6 (58) RULA bending down score B Between 1 and 3 (81) Between 4 and 6 (224) 7 and above (18) RULA bending down grand score Between 1 and 2 (1) Between 3 and 4 (15) Between 5 and 6 (96) 7 and above (210) RULA patient turning score A Between 1 and 3 (10) Between 4 and 6 (227) 7 and above (86) RULA patient turning score B Between 1 and 3 (11) Between 4 and 6 (193) 7 and above (119) RULA patient turning grand score Between 1 and 2 (1) Between 3 and 4 (15) Between 5 and 6 (96) 7 and above (210)
Statistics
Significant
χ2 = 1.890; d.f. = 3
P = 0.595
χ2 = 6.420; d.f. = 2
P = 0.040*
No (n: 13)%
93.9
6.1
96.7 97.6 96.9 89.1
3.3 2.4 3.1 10.9
95.5 98.3
2.5 1.7
χ2 = 0.969; d.f. = 1
P = 0.325
97.5 95.1 100.0
2.5 4.9 0.0
χ2 = 1.717; d.f. = 2
P = 0.424
100.0 95.2 100.0 100.0
0.0 4.8 0.0 0.0
χ2 = 2.719; d.f. = 3
P = 0.437
90.0 96.5 95.3
10.0 3.5 4.7
χ2 = 1.159; d.f. = 2
P = 0.560
100.0 95.3 96.6
0.0 4.7 3.4
χ2 = 0.801; d.f. = 2
P = 0.670
100.0 93.3 94.8 96.7
0.0 6.7 5.2 3.3
χ2 = 0.918; d.f. = 3
P = 0.821
*P < 0.05; **P < 0.001.
hospital while they also continue their bachelor’s/master’s degree education. This situation may cause excessive fatigue in nurses, which may result in higher frequency of MSD symptoms. The findings of the present study, in line with similar studies, show that psychosocial factors and work conditions were found to be associated with the presence of MSD symptoms. Occupational lower back pain was found to be associated with the daily workload of the institution and income satisfaction (Dündar et al. 2010).
© 2014 International Council of Nurses
In developing countries, nurses immigrate to European, Northern and other wealthy countries to work in better conditions and to earn an increased income. This migration leads to the problem of inadequate staffing in developing countries. Having MSD symptoms affects the cost of nursing and has significant social effects inasmuch as MSD symptoms cause sick leave and absenteeism among nurses (Harcombe et al. 2009; Tinubu et al. 2010). Nurse shortages are significant for MSD prevalence. In Uganda, there are six nurses per 100 000 people, there are 236
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Table 3 Logistic regression analysis of musculoskeletal disorder symptoms among body parts According to body parts having musculoskeletal symptoms
Variables (%)
Having leg symptoms (n = 208)
Type of shift work (with symptom %) 08–18/18–08 (16.3) 08–16/16–08 (42.8) 08–20/20–08 (40.9) Total years in nursing (with symptom %) Working 0–2 years (23.6) Working 3–10 years (62.0) Working 11–20 years (14.4) Type of hospital (with symptom %) Private hospital (22.1) Public hospital (63.2) University hospital (14.7) Frequency of exercise (with symptom %) At least three times a week (15.8) Never (84.2) Total years in nursing (with symptom %) 0–2 years (17.9) 3–10 years (64.7) 11–20 years (17.4) Frequency of changes in working order (with symptom %) Weekly (1.6) Monthly (17.1) Irregular (81.3) To have adequate assistance from support staff (with symptom %) Always (30.6) Often (50.0) Occasionally (14.7) Never (4.7) RULA patient turning score A (with symptom %) Between 1 and 3 (1.6) Between 4 and 6 (70.0) 7 and above (28.4)
Having lower back symptoms (n = 190)
Unadjusted OR
95% CI
1.00 7.938 3.357
1.958–32.178 0.300–37.624
1.00 3.538 3.134
1.152–10.860 1.255–7.827
1.00 1.395 0.422
0.699–2.784 0.188–0.947
1.00 1.407
0.660–3.000
1.00 0.536 1.288
0.234–1.228 0.619–2.680
1.00 0.144 0.691
0.032–0.647 0.353–1.350
1.00 1.619 2.850 3.500
0.517–5.075 0.793–10.246 1.111–11.030
1.00 6.275 7.448
1.401–28.113 1.568–35.388
95% CI, 95% confidence interval; OR, odds ratio; RULA, Rapid Upper Limb Assessment.
nurses per 100 000 people in Turkey, and 736 nurses per 100 000 people in the WHO European Region (Munabi et al. 2014; World Health Organization (WHO) 2013). In Turkey, there are some new regulations to increase numbers of students and academic staff in nursing schools to prevent nurse shortages. In order to prevent absenteeism due to MSDs, it is necessary to have enough nurses in clinics who are well educated and qualified. Smoking and absence of regular exercise have been reported as increasing the risk level of MSD injuries in previous studies (Long et al. 2012). A significant association between smoking
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habit and MSD symptom occurrence was not detected in this investigation. However, the high prevalence of MSD symptoms among persons who described their health status as ‘poor’ or ‘very poor’ suggests that this might have been expected. In the literature, there are studies on prevention of ergonomic risks for nurses and health promotion among them. These studies and systematic reviews evaluate the effects of interventions such as back schools, ergonomic training, antismoking education and exercise programmes intended to reduce work-related MSDs. Studies report that multiple interventions could produce more significant outcomes which
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suggest participatory ergonomic interventions, engineering and administrative controls. (Black et al. 2011; Côté et al. 2013; Lim et al. 2011). In the countries that have nurse shortages, low resources and low income, there are more MSDs. Given these circumstances, it might be that organizational factors have significant effects on the prevalence of MSD (Munabi et al. 2014). In the present study, most of the predictors for MSD symptoms in the low back and leg regions of the ICU nurses were the result of organizational factors such as type of hospital, type of shift work, frequency of changes in work schedule and inadequate assistance from support staff. There are transfer aids and lifts that are used to decrease the ergonomic risks in patient-care environments. There were no transfer aids or lifts in this study, which was conducted in 51 ICUs. Studies show that in low-resource settings, nurses do not have transfer aids to use during manual patient handling (Munabi et al. 2014). With regard to the situation in the USA, European countries and some Asia-Pacific countries, previous studies have found that lifts were effective tools during the manual handling of patients. Despite that, even in units where lifts are present, their use may be inadequate because of the time loss involved and the difficulty in their use (Lee et al. 2013). As expected by the researchers, the RULA scores indicated that ICU nurses’ postures needed to be investigated and changed immediately. Ergonomic programmes for healthcare workers should include periodic and systematic activities to determine the risks in the workplace. Also, this process requires direct communication with workers. Nevertheless, how can these services be provided in developing countries or those without sufficient occupational health services? A law in Turkey related to workers’ health came into force in 2012 but has not been implemented yet (Ministry of Labour and Social Security (MLSS) 2012). Therefore, this problem could be solved by developing occupational health units in hospitals and employing trained occupational health nurses urgently. These nurses are able to analyse the risks for healthcare workers by interacting with them in their workplace (Esin et al. 2008). With the aim of increasing awareness of the issue, occupational health practices should be included in the nursing curriculum. Besides modern and interactive undergraduate/postgraduate courses, service training could be organized for staff nurses. In addition, cooperation with national and international civil society organizations could be organized. As with every study, this study has some limitations: although a representative sample was used in the study, the administrators of the hospitals in which the study was carried out gave permission for only one observation per nurse by a single researcher. To have more reliable data, ICU nurses should be
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observed in the same position at least twice, allowing for a mean score for observations.
Conclusions This study has revealed the prevalence of MSD symptoms due to working conditions and variables that had an effect on such symptoms among ICU nurses. The main factors in the occurrence of MSD symptoms were found to be associated with risks stemming from the institution. The need for institutional organization aimed at reducing the frequency of MSD is shown in multiple studies. In this context, the personal characteristics of nurses are found to be less important than institutional features in the occurrence of MSD. The study sample is representative of all adult ICUs in Turkey, and this study is one of the first studies that used a reliable tool in data acquisition to focus on a specific area in nursing practice, namely determining ICU nurses’ ergonomic risks.
Implications for nursing and health policy The findings of this study may be used in programmes intended at prevention of musculoskeletal systems among healthcare professionals by nurses and physicians providing information on occupational health. Health policy makers should develop occupational health units in all hospitals to prevent nurses’ and other health professionals’ health problems by creating a healthy work environment. In these units, ‘ergonomic risk prevention programmes’ should be implemented by occupational health teams in which expert occupational health nurses take part. At this point, occupational health nursing education can be re-checked in the countries such as Turkey.
Acknowledgements We thank all public, university and private hospital’s administrations that gave permission to collect data for this study.
Author contributions Study conception/design: Duygu Sezgin and M. Nihal Esin. Data collection/analysis: Duygu Sezgin. Drafting of manuscript: Duygu Sezgin and M. Nihal Esin. Critical revisions for important intellectual content: M. Nihal Esin. Supervision: M. Nihal Esin. Statistical expertise: M. Nihal Esin. Administrative/ technical/material support: Duygu Sezgin and M. Nihal Esin.
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