581933

HFSXXX10.1177/0018720815581933Human FactorsMSD Pain in Nursing Workers

Prevalence of Musculoskeletal Disorders for Nurses in Hospitals, Long-Term Care Facilities, and Home Health Care: A Comprehensive Review Kermit G. Davis and Susan E. Kotowski, University of Cincinnati, Cincinnati, Ohio Objective: The aim of this study was to determine the prevalence of musculoskeletal pain and reported injuries for nurses and nursing aides. Background: Nurses and nursing aides suffer from work-related pain and musculoskeletal disorders (MSDs). Although there have been a plethora of studies on MSDs, an overall understanding of the prevalence of MSDs and pain can lead to better prioritization of research needs with respect to the health care industry. Method: A total of 132 articles on prevalence of MSD pain and injuries were included in the review. All articles were published in peer-reviewed Englishspeaking journals and subjected to a quality review. Results: Reported prevalence of MSD pain for nurses and nursing aides was highest in the low back, followed by shoulders and neck. However, the majority of the studies have been concentrated on 12-month pain in the low back and predominantly in hospitals. Few researchers have investigated pain in the upper and lower extremities (less than 27% of the studies). Even fewer researchers have evaluated reported injuries or even subjective losttime injuries (less than 15% of the studies). Conclusion: MSD pain in the nursing profession has been widely investigated worldwide, with a major focus on low-back pain. Given new directions in health care, such as patients who live longer with more chronic diseases, bariatric patients, early mobility requirements, and those who want to be at home during sickness, higher prevalence levels may shift to different populations— home health care workers, long-term care workers, and physical therapists—as well as shift to different body regions, such as shoulders and upper extremities. Keywords: spine, low back, biomechanics, anthropometry, work physiology, wrist, upper extremity, musculoskeletal system (musculoskeletal disorders, cumulative trauma disorder), nursing and nursing systems, health care/health systems

Address correspondence to Kermit G. Davis, University of Cincinnati, Low Back Biomechanics and Workplace Stress Laboratory, 160 Panzeca Way, Kettering Lab, Cincinnati, OH 45267-0056, USA; e-mail: [email protected]. HUMAN FACTORS Vol. XX, No. X, Month XXXX, pp. 1­–39 DOI: 10.1177/0018720815581933 Copyright © 2015, Human Factors and Ergonomics Society.

Introduction Musculoskeletal disorders (MSDs) plague the nursing profession (nurses and nursing aides). National injury costs in the United States for nurses and nursing aides (in 2013 U.S. dollars) have been estimated to be $1.6 billion, $344 million, $192 million, $65 million, and $134 million for low back, shoulder, knee, neck, and hand/wrist, respectively (Waehrer, Leigh, & Miller, 2005). The average MSD claim costs have been reported between $6,190 to $93,225 (Alamgir et al., 2008; Badii, Keen, & Yassi, 2006; Haglund, Kyle, & Finkelstein, 2010), and average low-back claim costs ranged from $2,270 to $14,235 (Black, Shah, Busch, Metcalfe, & Lim, 2011; Charney, Simmons, Lary, & Metz, 2006; Cohen-Mansfield, Culpepper, & Carter, 2006; Goldman, Jarrard, Kim, Loomis, & Atkins, 2000; Lipscomb, Schoenfisch, Myers, Pompeii, & Dement, 2012; Meyer & Muntaner, 1999; Park, Bushnell, Bailer, Collins, & Stayner, 2009; Stichler, Feiler, & Chase, 2012). Based on these cost figures, MSDs have placed a significant burden on the health care sector and specifically on the health care workers. Understanding how MSDs impact workers, specifically nurses and nursing aides in this case, requires quantification of the prevalence of pain, reports of injuries and disability, and the understanding of the potential risk factors for these health outcomes. Ferguson and Marras (1997) developed a model for the progression of lowback disorders that can be the foundation for the progression of MSDs. The progression from stressor to disability has the following stages: (1) discomfort, (2) symptoms, (3) disorder (injury or illness), (4) incidence, (5) restricted days, (6) lost days, and (7) disability. In the current review, we utilized this progression to evaluate the different MSD outcomes for health care professionals. Further, the current review focused on the health outcomes and not the risk factors associated with

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2 Month XXXX - Human Factors

MSD outcomes. Other researchers have conducted reviews of the studies investigating the risk factors (Bakker, Verhagen, van Trijffel, Lucas, & Koes, 2009; Buckle, 1987; Kuiper et al., 1999; Nelson & Baptiste, 2006). The authors of these reviews have identified patient-handling tasks to be associated with MSDs, specifically in the low back. The objectives of the current review were to (a) determine the overall prevalence of MSD outcomes for nurses and nursing aides; (b) determine whether prevalence of MSDs vary by body region, occupational classification, and health care facility; and (c) identify the limitations of the understanding of MSD prevalence (e.g., where are the gaps). Based on the review, priorities will be identified to fill the gaps and lead to a better understanding of pain and suffering that nurses and nursing aides experience worldwide, specifically identifying body regions, outcomes (e.g., lifetime, yearly, monthly, current), and facilities that need to have more research initiated. Method

A comprehensive literature review was conducted to identify all published articles on the reported prevalence of MSDs in nurses and nursing aides. The review followed the critical procedures of Pluye and Hong (2014) and the Mixed Methods Appraisal Tool (MMAT). Each article was rated based on the criteria for qualitative and quantitative random designs, quantitative nonrandom designs, and mixed methods (Pluye et al., 2011). Any article that was scored less than 25% on quality was eliminated from the analyses but reported in the summary table. Although the majority of the studies concentrated on the prevalence of MSDs in nurses and nursing aides, there were several studies that included general health care professionals as the subject population without differentiating exact professional discipline. Search Methods

A search for articles was completed over a 2-year period (September 2012 to September 2014), utilizing two search engines: Google Scholar and Thomson Reuters Web of Knowledge, which includes Medline, BIOSIS, Data

Citation Index, Inspec, and Web of Science Core Collections. Combinations of words were entered into both search engines. The search words utilized in the search included nurses, nursing, nursing aides, long-term care facilities, hospitals, home healthcare, musculoskeletal disorders, low back, hand, wrist, knee, shoulder, neck, discomfort, injuries, and pain. Inclusion/Exclusion Criteria

The following four inclusion criteria were used to select the articles to be included into this review: (a) full article study investigating the prevalence of pain or MSD injury in one of the targeted body regions for nurses and nursing aides, which included the following classifications: nurses, nursing aides, clinical nurse, assistant nurse, health care assistant, home care aide, practical nurse, and professional nurse; (b) published as a full-text article in an Englishlanguage peer-reviewed journal; (c) focus on health care setting, including hospitals, longterm care facilities, and home health care; (d) published prior to September 1, 2014. No exclusion criteria were based upon quality of the assessment, country of origin, or study design. Results In all, a total of 132 articles were included in the review. Table 1 provides a summary of the studies, including study population, study design, type of MSD outcome (e.g., pain assessment in lifetime, previous 12 months, previous 3 to 6 months, and current), reported MSD injuries (using company injury or compensation records), and lost-time injuries (subjectively reported) as well as the body region of pain/ injury (e.g., low back, shoulder, neck, upper extremity, and lower extremity). Overall, most of the research into MSD pain and injuries for nurses and nursing aides utilized subjective surveys to take a snapshot of the health status (78%). A prospective design was utilized in only 19% of the studies, with 88% of these prospective studies utilizing a survey to assess MSD pain and injuries. Authors of four studies investigated previous injuries utilizing a retrospective design. Only two studies utilized a clinical evaluation to determine the presence of pain or injury. The majority of study

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3

Study Population

Study Design

Ahmadi, Rezaiee, 348 nurses in two Cross-sectional hospitals in Iran study with & Hashemian survey (2014) 1-year Alamgir et al. 8,636 nurses in prospective (2008) hospitals and study long-term care facilities in Canada Cross-sectional 129 nurses and Alexopoulos, study with 264 caregivers Burdorf, & survey for in hospitals in Kalokerinou, the Netherlands Netherlands (2003, 2006) (1998–1999) and 351 nurses and Greece in hospitals in (2001–2002) Greece Cross-sectional Alexopoulos 448 nurses in 6 study with et al. (2011) hospitals in survey Greece Cross-sectional 57 nurses from Alperovitchstudy with hospital and Najenson, survey 54 nurses from Sheffer, Treger, home health in Finkels, & Kalichman (2014) Israel Cross-sectional Anap, Iyer, & Rao 212 nurses in study with (2013) unknown survey number of hospitals in India

Author

X

X

X

QUAN-NR 100% QUAN-NR 75%

QUAN-D 75%

12Mon

X

Lifetime

QUAN-NR 100%

QUAN-NR 75%

QUAN-NR 75%

MMAT Criteriaa X

Current

3–6 Months

Body Region

X

X

X

X

X

X

X

X

X

X

X

X

X

X

 

X

 

 

(continued)

 

Lost Upper Lower MSD Days Back Shoulder Neck Extremity Extremity

Reporting Period and Type

Table 1: Summary of the Studies Included in Review, Including Study Population, Study Design, MMAT Criteria, Type of Pain and Injury Outcome, and Body Region

4

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Study Population

Study Design

Andersen et al. (2014)

Cross-sectional 5,017 health study with care workers in survey nursing homes in Denmark Ando et al. (2000) 314 full-time RNs Cross-sectional study with in hospitals in survey Japan Cross-sectional Arad & Ryan 831 nurses in study with (1986) a hospital in survey Australia Cross-sectional Attar (2014) 200 RNs in a hospital in Saudi study with survey Arabia Cross-sectional Attarchi, Raeisi, 454 nurses study with and NAs in a Namvar, & survey Golabadi (2014) hospital in Iran Cross-sectional Beija et al. (2005) 193 nurses and study with 157 other survey workers in hospital in Tunisia Botha & Bridger 100 nurses from 3 Cross-sectional (1998) private hospitals study with survey in South Africa and direct observation Brulin et al. (1998) 361 home health Cross-sectional study with care workers in survey Sweden

Author

Table 1: (continued)

QUAN-NR 100%

X

X

QUAN-NR 75%

QUAN-DE 100%

X

QUAN-NR 100% X

X

QUAN-NR 100%

X

X

QUAN-NR 75%

X

X

Current

QUAN-NR 75%

12Mon X

Lifetime

QUAN-NR 75%

MMAT Criteriaa

3–6 Months

Body Region

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

(continued)

X

X

 

X

X

 

 

 

Lost Upper Lower MSD Days Back Shoulder Neck Extremity Extremity

Reporting Period and Type



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5

Study Population

Study Design

Burton et al. (1997)

1,783 nurses from Cross-sectional study with hospitals in booklet of Belgium surveys Cross-sectional Byrns, Reeder, Jin, 136 RNs in the study with & Pachis (2004) hospitals in survey United States 104 RNs, 11 LPNs/Cross-sectional Callison & study with LVNs, and 27 Nussbaum, survey NAs in hospital (2012) in United States and direct observation Cross-sectional 303 RNs in Cameron, survey and hospitals in Armstronginterview Stassen, Kane, & United States Moro (2008) 2-year Cheung (2010) 388 nursing prospective students in study with Hong Kong survey Cross-sectional Cheung, Gillen, 491 home study with care nursing Faucett, & survey personnel in Krause (2006) hospital in Hong Kong

Author

Table 1: (continued)

X

X

X

QUAN-NR 100%

QUAN-DE 75%

QUAN-NR 100%

X

12Mon

X

X

Lifetime

QUAN-DE 50%

QUAN-NR 75%

QUAN-NR 100%

MMAT Criteriaa

X

X

Current

3–6 Months

Body Region

X

X

X

X

X

X

X

X

X

X

X

X

X

(continued)

X

 

X

X

 

 

Lost Upper Lower MSD Days Back Shoulder Neck Extremity Extremity

Reporting Period and Type

6

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Cross-sectional 3,159 nursing study with personnel in survey large medical center in China Cross-sectional 246 health care Cunningham, study with personnel in Flynn, & Blake survey hospital in (2006) Ireland Cross-sectional Cust, Pearson, & 413 RNs and study with Mair (1972) 343 NAs in survey 1 hospital in Scotland Cross-sectional Daraiseh et al. 34 RNs in 2 study with (2003) hospitals in survey United States Cross-sectional D’Arcy, Sasai, & 2,692 NAs in study with Stearns (2012) 582 long-term national survey facilities in United States 2-year Daws (1981) 2,000 NAs in prospective 1 hospital in United Kingdom study using survey

375 nurses in Cross-sectional hospital in Iran study with survey

Choobineh, Movahed, Tabatabaie, & Kumashiro (2010) Chiou, Wong, & Lee (1994)

Study Design

Study Population

Author

Table 1: (continued)

X

QUAN-DE 75%

QUAN-NR 25%

QUAN-NR 100%

X

X

QUAN-NR 75%

QUAN-DE 50%

X

Lifetime

QUAN-NR 100%

QUAN-NR 100%

MMAT Criteriaa

X

X

X

12Mon

X

X

X

Current

X

3–6 Months

Body Region

X

X

X

X

X

X

X

X

X

X

X

X

X

X

(continued)

 

 

X

 

 

 

X

Lost Upper Lower MSD Days Back Shoulder Neck Extremity Extremity

Reporting Period and Type



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7

Study Population

Cross-sectional study with survey at national conference Cross-sectional study with interviews Cross-sectional study with survey with direct observation Cross-sectional study with survey and clinical examination Cross-sectional study with survey

Study Design

148 nurses in Dundara, Ozmenb, Ilgunc, hospital in Turkey Cakmakcid, & Alkise (2010) 97 home health Cross-sectional Elert, Brulin, observation care personnel Gerdle, & and in Sweden Johansson quantification (1992)

Dulon, Kromark, 1,390 nurses and NAs in 68 longSkudlik, & Nienhaus (2008) term facilities in Germany

Dehlin, Hedenrud, 267 NAs in & Horal (1976) hospital in Sweden 50 nurses and 39 Dehlin & NAs in hospital Jaderberg in Sweden (1982)

655 nurses de Castro, attending Cabrera, Gee, conference in Fujishiro, & Philippines Tagalog (2009)

Author

Table 1: (continued)

X

QUAN-NR 100%

QUAN-NR 100%

QUAN-NR 100%

X

QUAN-DE 25%

X

12Mon

X

X

Lifetime

QUAN-DE 100%

QUAN-DE 100%

MMAT Criteriaa

X

X

X

Current

3–6 Months

Body Region

X

X

X

X

X

X

X

X

X

X

X

X

X

(continued)

 

 

 

 

 

 

Lost Upper Lower MSD Days Back Shoulder Neck Extremity Extremity

Reporting Period and Type

8

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X

X

X

X

X

QUAN-NR 100%

QUAN-DE 100%

QUAN-NR 100%

QUAN-NR 75%

QUAN-DE 100%

Cross-sectional study with survey

Cross-sectional study with survey

15-month prospective study with surveys

Cross-sectional study with survey

Cross-sectional study with survey

El-Sayyad, Naushad, Mathew, & Kumar (2013)

QUAN-NR 75%

Current

Cross-sectional study with survey

12Mon

116 nurse and 70 other health care workers in 2 hospitals in Iran 846 nurses in Engels, van der Gulden, Senden, 4 long-term facilities in the & van der Hof Netherlands (1996) Eriksen (2003) 6,485 NAs in long-term facilities, hospitals, and homes in Norway 4,266 NAs in Erikson, long-term Bruusgaard, & Knardahl (2004) facilities, hospitals, and homes in Norway Estryn-Beharl et 1,505 health care workers in 26 al. (1990) departments in hospitals in France Fabunmi, Oworu, 214 nurses in 1 hospital in & Odunaiya Nigeria (2008)

Lifetime

Study Design

MMAT Criteriaa

X

3–6 Months

Body Region

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

(continued)

X

 

 

X

X

 

Lost Upper Lower MSD Days Back Shoulder Neck Extremity Extremity

Reporting Period and Type

Study Population

Author

Table 1: (continued)



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9

Study Population

Study Design

2-year Fanello, Jousset, 272 health care prospective staff in hospital Roquelaure, study with in France Chotardsurveys Frampas, & Delbos (2002) 1-month Feldstein, Valanis, 40 RNs, 7 NAs, prospective and 8 orderlies Vollmer, study using in 2 hospitals Stevens, & survey and in the United Overton (1993) physical States assessment Cross-sectional 854 health care Felknor, Aday, study with workers in 10 Burau, Delclos, survey hospitals in & Kapadia Costa Rica (2000) Cross-sectional Feng, Chen, & 204 NAs in 31 study with Mao (2007) long-term survey facilities in Taiwan 440 RNs and 655 Cross-sectional Fochsen, study with NAs in hospital Josephson, survey in Sweden Hagberg, Toomingas, & Lagerstrom (2006) Cross-sectional 60 nurses in French, Flora, Ping, Bo, & Rita hospital in Hong study with survey Kong (1997)

Author

Table 1: (continued)

X

X

QUAN-NR 75%

QUAN-DE 50%

12Mon

X

X

Lifetime

QUAN-NR 100%

QUAN-NR 100%

QUAN-NR 100%

QUAN-NR 100%

MMAT Criteriaa

Current

X

3–6 Months

Body Region

X

X

X

X

X

X

X

X

X

X

X

X

X

(continued)

 

X

 

 

 

 

Lost Upper Lower MSD Days Back Shoulder Neck Extremity Extremity

Reporting Period and Type

10

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Study Population

Study Design

Garg & Owen (1992)

38 NAs in nursing 8-month home in United prospective study using States survey and observation 38 NAs in nursing Cross-sectional Garg, Owen, & Carlson (1992) home in United study with survey States Cross-sectional Genevay et al. 167 NAs, 233 study with RNs, and (2011) survey 809 other health care professionals in unknown number of hospitals in Switzerland Cross-sectional 97 health care Gerdle, Brulin, study with providers Elert, & survey Granlund (1994) in homes in Sweden Cross-sectional Ghilan et al. 687 nurses study with (2013) in multiple survey hospitals in Yemen Cross-sectional Gimeno, Felknor, 475 health care study with Burau, & Delclos workers in 10 survey hospitals in (2005) Costa Rica

Author

Table 1: (continued)

QUAN-NR 50%

X

X

X

X

QUAN-NR 100%

X

X

X

QUAN-NR 100%

QUAN-NR 75%

X

Current

QUAN-NR 75%

12Mon X

Lifetime

QUAN-NR 100%

MMAT Criteriaa

3–6 Months

Body Region

X

X

X

X

X

X

X

X

X

X

X

X

(continued)

 

 

X

 

 

 

Lost Upper Lower MSD Days Back Shoulder Neck Extremity Extremity

Reporting Period and Type



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11

Study Population

Study Design

Green (1996)

Cross-sectional 10 health care study with workers in direct hospital in United Kingdom observation and structured interview Guo et al. (1995) Unknown number Cross-sectional study with of caregivers annual survey in long-term of national facilities, health hospitals in United States Unknown number Cross-sectional Guo, Tanaka, study with of caregivers Halperin, & annual survey Cameron (1999) in long-term of national facilities, health hospitals in United States Cross-sectional Harber et al. 550 nursing study with (1985) personnel in survey hospital in United States Cross-sectional 181 nurses in Harcombe, study with unknown McBride, survey Derrett, & Gray number of hospitals, home (2009) health, long-term care, and other facilities in New Zealand

Author

Table 1: (continued)

QUAN-NR 75%

X

X

3–6 Months

Body Region

X

X

X

X

X

X

X

X

(continued)

X

 

 

 

 

Lost Upper Lower MSD Days Back Shoulder Neck Extremity Extremity

X

X

Current

QUAN-NR 50%

X

12Mon

X

Lifetime

QUAN-NR 75%

QUAN-NR 75%

MM 66%

MMAT Criteriaa

Reporting Period and Type

12

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Study Population

Study Design

2-year 345 nurses and Hartvigsen, Lauritzen, Lings, NAs in homes in prospective study with Denmark & Lauritzen survey (2005) Cross-sectional Hofmann, Stossel, 2,176 nurses study with in hospital in Michaelis, survey Germany Nubling, & Siegel (2002) Cross-sectional Hollingdale & 168 nurses in 2 study with Warin (1997) hospitals in United Kingdom survey 1-year 5,046 health Holtermann, prospective care workers Clausen, study with in unknown Jørgensen, survey and number of Burdorf, & interview Andersen (2013) long-term care facilities in Denmark Horneij, Jensen, 443 NAs in home 18-month prospective health care Holmström, & study with facilities in Ekdahl (2004) survey Sweden Cross-sectional Jang et al. (2007) 21 health care survey workers in and direct hospital in observation United States

Author

Table 1: (continued)

X

X

X

QUAN-NR 75%

QUAN-NR 75%

QUAN-NR 75%

X

12Mon

X

X

Lifetime

QUAN-NR 75%

QUAN-NR 75%

QUAN-NR 100%

MMAT Criteriaa

X

X

X

Current

3–6 Months

Body Region

X

X

X

X

X

X

X

X

(continued)

 

 

 

 

 

 

Lost Upper Lower MSD Days Back Shoulder Neck Extremity Extremity

Reporting Period and Type



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13

Study Population

Study Design

Jensen et al. (2006)

163 health care workers in hospital in Denmark

2-year prospective randomized control trial with observation and survey 6-month 51 health care Johnsson, prospective workers in Carlsson, & study with hospitals and Lagerström observation homes in (2002) and survey Sweden 3-year 285 health care Josephson, prospective workers in Lagerstrom, study with hospital in Hagberg, & survey Sweden Hjelm (1997) Cross-sectional June & Cho (2010)1,345 nurses in study with 22 hospitals in survey South Korea 1,600 health care Cross-sectional Karahan, Kav, study with workers in 6 Abbasoglu, & survey hospitals in Dogan (2009) Turkey Cross-sectional Kee & Seo (2007) 162 nurses in study with hospitals in survey South Korea

Author

Table 1: (continued) Body Region

X

X

QUAN-NR 100%

QUAN-NR 50%

X

X

X

X

QUAN-DE 75%

X

X

X

X

X

X

X

(continued)

X

 

 

 

 

 

Lost Upper Lower MSD Days Back Shoulder Neck Extremity Extremity

X

3–6 Months

X

X

Current

QUAN-NR 75%

X

12Mon

X

Lifetime

QUAN-NR 75%

QUAN-NR 100%

MMAT Criteriaa

Reporting Period and Type

14

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Study Population

Study Design

7-year 12,357 RNs, Kim, Dropkin, 5,397 NAs, and retrospective Spaeth, Smith, study using & Moline (2012) 29,589 other compensation workers in 15 records hospitals in United States Cross-sectional Kim et al. (2014) 978 nurses, 86 study with PCAs, and survey 275 others in 2 hospitals in United States 102 nurses from Laboratory study Kjellberg, investigating hospitals in Lagerström, & different lifting Hagberg, (2003) Sweden devices Knibbe & Frielle 189 RNs and 165 6-month (1996) NAs in homes in prospective study with Netherlands survey 12-month Knibbe & Frielle 298 nurses prospective (1999) in home study using health care in logs and Netherlands surveys 10-year Koehoorn, Cole, 5,029 health retrospective Hertzman, & Lee care workers case-control in 1 hospital in (2006) study using Canada compensation records

Author

Table 1: (continued)

QUAN-NR 75%

QUAN-NR 100%

X

X

Current

QUAN-NR 100%

X

12Mon

X

X

Lifetime

QUAN-NR 75%

QUAN-NR 100%

QUAN-NR 100%

MMAT Criteriaa

X

X

3–6 Months

Body Region

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

(continued)

X

 

X

 

X

 

Lost Upper Lower MSD Days Back Shoulder Neck Extremity Extremity

Reporting Period and Type



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15

Study Population

Study Design

3-year 3,769 health Koehoorn, retrospective care workers Demers, study using in 1 hospital in Hertzman, company injury Canada Village, & records Kennedy (2006) Cross-sectional Kromark, Dulon, 834 RNs and study with 556 NAs in 68 Beck, & survey and Nienhaus (2009) long-term care facilities and 18 examination home health services in Germany Kulkarni & 25 nurses in a Cross-sectional Darsana (2014) hospital in India study with survey Cross-sectional 165 RNs, 255 Lagerstrom, study with NAs, and 268 Wenemark, survey Hagberg, Hjelm, auxiliary nurses in hospital in & the Moses Sweden Study Group (1995) 3-year Lagerstrom et al. 348 health care prospective (1998) workers in study with hospital in survey Sweden

Author

Table 1: (continued)

X

QUAN-NR 100%

QUAN-DE 100%

X

Current

QUAN-NR 50%

X

12Mon

X

Lifetime

QUAN-DE 75%

QUAN-NR 75%

MMAT Criteriaa

3–6 Months

Body Region

X

X

X

X

X

X

X

X

X

X

X

X

X

X

(continued)

X

X

X

 

X

Lost Upper Lower MSD Days Back Shoulder Neck Extremity Extremity

Reporting Period and Type

16

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Study Population

Study Design

2-year Lamy et al. (2014) 1,896 RNs and prospective NAs in 7 study with hospitals in survey Finland Cross-sectional 344 health care Landry, Raman, study with workers in Sulway, survey hospital in Golightly, & Kuwait Hamdan (2008) Cross-sectional 361 nurses in Lee, Faucett, Gillen, Kraus, & national society study with in United States survey Landry (2010) Cross-sectional Lee & Chiou 3,159 nursing study with (1994) personnel in survey hospitals in Taiwan Cross-sectional Leighton & Reilly 1,134 nursing study with (1995) personnel in survey hospitals in United Kingdom Cross-sectional Lin, Tsai, Chen, & 217 nurses in study with Huang (2012) 1 hospital in survey Taiwan Cross-sectional Lipscomb, Trinkoff, 1,163 RNs in study with Brady, & Geiger- health care survey facilities in 2 Brown (2004) states of United States

Author

Table 1: (continued)

X

X

X

QUAN-NR 100%

QUAN-DE 100% QUAN-NR 75%

X

QUAN-NR 100%

X

12Mon

X

Lifetime

QUAN-NR 75%

QUAN-NR 100%

QUAN-NR 100%

MMAT Criteriaa

X

X

X

X

Current

3–6 Months

Body Region

X

X

X

X

X

X

X

X

X

X

X

X

(continued)

 

 

 

 

 

 

 

Lost Upper Lower MSD Days Back Shoulder Neck Extremity Extremity

Reporting Period and Type



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17

Study Population

Study Design

Luime et al. (2004) 769 caregivers in 2-year prospective homes in the study with Netherlands survey Cross-sectional Lusted, Carrasco, 64 nurses in 1 study with hospital in Mandyk, & survey Australia Healey (1996) and 1-year retrospective study with compensation records Cross-sectional 627 nurses in Majumdar, Pal, military hospitals study with & Majumdar survey in India (2014) 8-year 1,195 nurses Maul, Läubli, prospective in hospital in Klipstein, & study with Germany Krueger (2003) survey Mendelek, Caby, 90 RNs, 94 NAs, Cross-sectional study with and 52 other Pelayo, & Kheir survey health care (2013) workers in 1 hospital in Lebanon Cross-sectional 245 nurse Moreira, Sato, study with Foltran, Silva, & technicians survey and LPNs in a Coury (2014) hospital in Brazil

Author

Table 1: (continued)

X

QUAN-NR 75%

X

X

X

QUAN-NR 50%

X

QUAN-DE 100%

X

X

QUAN-NR 75%

X

X

Current

QUAN-DE 50%

12Mon X

Lifetime

QUAN-NR 50%

MMAT Criteriaa

X

3–6 Months

Body Region

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

(continued)

X

 

 

X

X

 

Lost Upper Lower MSD Days Back Shoulder Neck Extremity Extremity

Reporting Period and Type

18

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Study Population

Study Design

Cross-sectional 775 nurses in 5 Munabi, study with hospitals in Buwembo, survey Kitara, Ochieng, Uganda & Mwaka (2014) 184 RNs and 164 Cross-sectional Nabe-Nielsen, study with other nursing Fallentin, survey personnel in Christensen, hospital in Jensen, & Denmark Diderichsen (2008) 10-year 469 nurses in 6 Niedhammer, prospective hospitals in Lert, & Marne study with France (1994) survey Owen, Garg, & 38 NAs in long- Cross-sectional Jensen (1992) term facilities in study with survey United States 286 RNs from a Cross-sectional Pahlevan, hospital in Iran study with Azizzadeh, survey Esmaili, Ghorbani, & Mirmohammadkhani (2014) Cross-sectional Punnett (1987) 76 health care study with personnel in survey hospital in United States

Author

Table 1: (continued)

QUAN-NR 50%

QUAN-NR 100%

X

X

QUAN-NR 75%

QUAN-NR 100%

X

QUAN-NR 100%

12Mon X

Lifetime

QUAN-NR 100%

MMAT Criteriaa

X

Current

3–6 Months

Body Region

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

(continued)

 

X

 

 

 

X

Lost Upper Lower MSD Days Back Shoulder Neck Extremity Extremity

Reporting Period and Type



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19

Study Population

Study Design

Cross-sectional 733 NAs, 216 Qin, Kurowski, study with Gore, & Punnett LPNs, 238 RNs, survey and 286 other (2014) and 7-year health care retrospective professionals study with in long-term compensation care facilities in records United States Cross-sectional Reed, Battistutta, 416 nurses in study with pediatric Young, & survey Newman (2014) hospital in Australia Reme, Dennerlein, 1,572 health care Cross-sectional study with workers in 2 Hashimoto, & survey Sorensen (2012) hospitals in United States Cross-sectional 269 RNs in Retsas & study with medical center Pinikahana survey in Australia (2000) Cross-sectional 62,566 RNs Serranheira, study with in unknown Cotrim, national survey number of Rodrigues, hospitals, home Nunes, & health, longSousa-Uva term care and (2012) other facilities in Portugal

Author

Table 1: (continued)

X

X

Current

QUAN-NR 75%

X

X

12Mon

X

Lifetime

QUAN-NR 100%

QUAN-NR 100%

QUAN-NR 100%

QUAN-NR 100%

MMAT Criteriaa

X

X

3–6 Months

Body Region

X

X

X

X

X

X

X

X

X

X

X

X

(continued)

 

X

X

X

 

Lost Upper Lower MSD Days Back Shoulder Neck Extremity Extremity

Reporting Period and Type

20

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Study Population

Study Design

Cross-sectional 2,140 RNs in Serranheira, study with unknown Cotrim, survey hospitals and Rodrigues, health care Nunes, & centers in Sousa-Uva Portugal (2012) Schluter, Dawson, 4,903 nurses and Cross-sectional study with & Turner (2014) midwives in survey Australia and New Zealand Cross-sectional Smedley, Egger 1,659 nurses in study with hospitals in P, Cooper, & United Kingdom survey Coggon (1995) 2-year Smedley, Egger 961 nursing prospective personnel in P, Cooper, & study with hospital in Coggon (1997) United Kingdom survey and company records 13 month Smedley et al. 587 nurses at prospective (2003) 2 hospitals in United Kingdom study with survey 2-year Smedley, Inskip, 1,366 nurses in prospective 3 hospitals in Buckle, Cooper, & Coggon (2005) United Kingdom study with survey

Author

Table 1: (continued)

X

QUAN-NR 75%

QUAN-NR 100%

QUAN-NR 100%

X

X

QUAN-NR 100%

X

12Mon

X

Lifetime

QUAN-NR 75%

QUAN-NR 75%

MMAT Criteriaa X

Current

X

3–6 Months

Body Region

X

X

X

X

X

X

X

X

X

X

X

(continued)

 

 

 

 

 

 

Lost Upper Lower MSD Days Back Shoulder Neck Extremity Extremity

Reporting Period and Type



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21

Study Population

Study Design

Cross-sectional 91 nursing Smith, Choi, study with personnel in Ki, Kim, & Yamagata (2003) nursing home in survey South Korea Cross-sectional 222 nursing Smith, Sato, study with students in Miyajima, survey Japan Mizutani, & Yamagata (2003) Smith, Wei, Kang, 180 RNs in Cross-sectional & Wang (2004) hospital in China study with survey Cross-sectional 844 nurses in Smith, Mihashi, study with Adachi, Koga, & hospital in survey Japan Ishitake (2006) Cross-sectional Smith & Leggat 260 nursing study with (2004) students in survey Australia Cross-sectional 241 RNs, 22 Sopajareeya, study with technical Viwatwongsurvey kasem, Lapvong- nurses, and 2 practical nurses watana, Hong, in 1 hospital in & Kalampakorn Thailand (2009) 3-year Stobbe, Plummer, 143 LPNs, 252 retrospective NAs, and Jensen, & study using 20 ATTs in 1 Attfield (1998) company injury hospital in records United States

Author

Table 1: (continued)

X

X

QUAN-DE 25% QUAN-NR 100%

QUAN-NR 75%

X

QUAN-NR 100%

X

12Mon

X

Lifetime

QUAN-NR 100%

QUAN-DE 75%

QUAN-DE 100%

MMAT Criteriaa

X

Current

3–6 Months

Body Region

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

(continued)

 

 

X

 

X

X

X

Lost Upper Lower MSD Days Back Shoulder Neck Extremity Extremity

Reporting Period and Type

22

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Study Population

Study Design

Cross-sectional Stubbs, Buckle, 3,912 nurses in study with Hudson, Rivers, hospitals in United Kingdom survey & Worringham (1983) Cross-sectional 138 nursing Swain, Pufahl, study with students in & Williamson United Kingdom survey (2003) Cross-sectional Takala & 143 nurses in 5 survey and Kukkonen (1987) hospitals in video analysis Finland Cross-sectional Tezel (2005) 120 nursing study with personnel in survey 4 hospitals in Turkey Cross-sectional 135 nursing Theodora, study with personnel in Dimosthenis, survey a hospital in Michael, Greece Athanasios, & Evaggelos (2005) Cross-sectional Tinubu, Mbada, 128 nurses in 3 study with hospitals in Oyeymi & survey Fabunmi (2010) Nigeria Cross-sectional Trinkoff, Brady, & 1,163 licensed study with mail Nielson (2003) nurses in survey hospitals, longterm facilities, and homes in United States

Author

Table 1: (continued)

QUAN-NR 100%

X

QUAN-NR 100%

X

X

12Mon

X

Lifetime

QUAN-DE 75%

QUAN-DE 100%

QUAN-NR 100%

QUAN-NR 75%

QUAN-NR 75%

MMAT Criteriaa

X

Current

X

3–6 Months

Body Region

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

(continued)

 

X

 

 

 

 

X

Lost Upper Lower MSD Days Back Shoulder Neck Extremity Extremity

Reporting Period and Type



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23

47 nurses at Vieira, Kumar, hospital in Coury, & Canada Narayan (2006) Violante et al. 587 RNs, 228 (2004) NAs, and 43 head nurses in hospital in Italy

Cross-sectional study with survey

Trinkoff, Lipscomb 1,163 licensed J, Geiger-Brown, nurses in hospitals, long& Brady (2002) term facilities, and homes in United States 2,273 nurses in Trinkoff, Le, United States Geiger-Brown, Lipscomb, & Lang (2006) 407 nurses in Vasihadou, hospital in Karvountzis, Greece Soumilas, Roumeliotis, & Theodosopoulou (1995) Videman, Ojaja, 174 nursing students in Riihima, & Finland Troup, (2005)

7.5 year prospective study using survey Cross-sectional study with survey Cross-sectional study with survey

15-month prospective study with survey Cross-sectional study with survey

Study Design

Study Population

Author

Table 1: (continued)

QUAN-NR 100%

X

X

X

QUAN-DE 100%

12Mon

X

X

Lifetime

QUAN-NR 100%

QUAN-NR 100%

QUAN-DE 100%

QUAN-DE 100%

MMAT Criteriaa

X

X

Current

X

3–6 Months

Body Region

X

X

X

X

X

X

X

X

X

X

X

X

X

(continued)

 

 

 

 

 

 

Lost Upper Lower MSD Days Back Shoulder Neck Extremity Extremity

Reporting Period and Type

24

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Study Population

Study Design

X

QUAN-NR 100%

12Mon

X

Lifetime

QUAN-NR 75%

QUAN-NR 100%

MMAT Criteriaa X

Current

X

3–6 Months

Body Region

X

X

X

X

X

X

X

 

 

X

Lost Upper Lower MSD Days Back Shoulder Neck Extremity Extremity

Reporting Period and Type

Note. MMAT = Mixed Methods Appraisal Tool; MSD = musculoskeletal disorder; RN = registered nurse; NA = nursing assistant; LPN = licensed practical nurse; LVN = licensed vocational nurse; PCA = patient care assistant; ATT = nurse attendant. a MMAT criteria is based on the checklist developed by Pluye and Hong (2014), which assesses quantitative studies with randomized designs (QUAN-R), quantitative studies with nonrandomized designs (QUAN-NR), quantitative descriptive study (QUAN-DE), qualitative studies (QUAL), and mixed methods (MM). Each study design had three or four criteria: all criteria satisfied = 100%, one criterion not fulfilled = 75% for four and 66% for three, two criteria not fulfilled = 50% for four and 33% for three, three criteria not fulfilled = 25% for four, and no criteria fulfilled = 0%. Shaded studies were eliminated from analysis based on less than 25% of criteria fulfilled.

Cross-sectional Warming, Precht, 113 RNs and study with 35 NAs in Suadicani, & survey hospital in the Ebbehøj (2009) Netherlands Wergeland et al. 19 RNs, 107 NAs, Cross-sectional (2003) 39 home nurses, study with survey 57 practical nurses, and 64 other in longterm facilities and home health care in Norway and Sweden Cross-sectional Yip (2001) 377 nurses in 6 study with hospitals in survey Hong Kong

Author

Table 1: (continued)

MSD Pain in Nursing Workers

25

Low Back

100

Percentage of Populaon (%)

90 80 70 65 60 55

50

44

40 35 30 20

20 14

10 0

Lifeme

Annual

Current

3 to 6 months

MSD Injury

Lost Time Injury

Figure 1. Prevalence of low back pain as a function of pain outcome: lifetime, previous 12 months, current (less than 7 days), 3 to 6 months, musculoskeletal disorder injury, and lost-time injury.

authors (67%) investigated nurses (registered or licensed), and 24% of the study authors investigated nursing aides. Approximately 28% of the studies included populations with more general health care workers or a nondesignated nursing and nursing aide population. The bottom line is that authors of most studies have assessed pain and injuries utilizing a self-reported crosssectional survey, which is good to understand pain frequency. The authors of the majority of studies investigated pain in the past 12 months (57%), followed by current pain (less than 7 days; 37%), lifetime pain (15%), and 3 to 6 months (10%). Authors of few studies investigated actual reported injuries (10%) or injuries with lost days (14%). When looking at the body regions, almost all of the researchers investigated pain in the low back (93%), with fewer researchers investigating MSD pain in the neck (47%) and shoulder (46%), upper extremity (27%), and lower (30%) extremities. A summary of the prevalence for each body region as a function of outcome type is found in

Figures 1 to 5. With the most data points, mean prevalence for low-back pain (Figure 1) was 65% for lifetime, 55% for previous year, 44% for previous 3 to 6 months, and 35% for current symptoms. Actual reported low-back injuries (MSDs reported in company injury reports) occurred in only 14% of nurses, and selfreported lost-day injuries occurred in 20%. Shoulder prevalence was slightly lower (Figure 2): lifetime at 54%, past year at 44%, past 3 to 6 months at 44%, current at 32%, reported MSDs at 24%, and subjective lost days at 12%. There were no data for lifetime prevalence for neck pain (Figure 3) and 42%, 48%, and 28% for past year, past 3 to 6 months, and current pain, respectively. The prevalence for reported neck injuries was 20% and for lost-day injuries was around 7%, although few studies went into these estimates. In Figure 4, the average prevalence of upper-extremity pain in past year and 3 to 6 months was 26% and 21%, respectively. Current upper-extremity pain prevalence was 15%. Again, authors of few studies investigated upper-extremity MSDs with a prevalence around

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26 Month XXXX - Human Factors

Shoulder

90

Percentage of Populaon (%)

80 70 60 54

50

44

44

40

32

30

24

20

12

10 0

Lifeme

Annual

Current

3 to 6 months

MSD Injury

Lost Time Injury

Figure 2. Prevalence of shoulder pain as a function of pain outcome: lifetime, previous 12 months, current (less than 7 days), 3 to 6 months, musculoskeletal disorder injury, and lost-time injury.

Neck

90

Percentage of Populaon (%)

80 70 60 50 40

No Data

48 42

30

28 20

20 10

7

0

Lifeme

Annual

Current

3 to 6 months

MSD Injury

Lost Time Injury

Figure 3. Prevalence of neck pain as a function of pain outcome: lifetime, previous 12 months, current (less than 7 days), 3 to 6 months, musculoskeletal disorder injury, and lost-time injury. Downloaded from hfs.sagepub.com at CARLETON UNIV on May 10, 2015

MSD Pain in Nursing Workers

Upper Extremity

70

Percentage of Populaon (%)

27

60 50 40 30

No Data

26

No Data

21

20 15 10

8

0

Lifeme

Annual

Current

3 to 6 months

MSD Injury

Lost Time Injury

Figure 4. Prevalence of upper-extremity pain as a function of pain outcome: lifetime, previous 12 months, current (less than 7 days), 3 to 6 months, musculoskeletal disorder injury, and lost-time injury.

8%. No data have been reported for lifetime prevalence or lost-day injuries for upper-extremity pain outcomes. For the lower-extremity pain outcomes (Figure 5), mean past yearly prevalence was 36%, and the 3- to 6-month and current prevalence were 38% and 20%, respectively. Again, authors of few studies investigated the report injuries (6% of workers reporting MSDs) and lost-time injuries (8% on average). No data have been published for lifetime prevalence of lower-extremity pain. The prevalence as a function of nursing category and health care facility is in Table 2. In general, the table of prevalence was sparse in many cells particularly with respect to lifetime pain and injuries (either reported or subjective lost time) as well as non-low-back pain outcomes in home health care and long-term care facilities. By far, low-back pain had the most cells filled with values. The prevalence for mixed populations (nurses, nursing aides, and other health care workers) tended to have higher prevalence of low-back pain than nurses or nursing aides by themselves. Hospitals had more studies investigating low-back

pain than either long-term care or home health care facilities. Although the prevalence of lowback pain varied among the different facilities as well as nurses and nursing aides, the trends were not consistent. Authors of a large number of the studies investigated nurses who work at hospitals for low-back outcomes. For shoulder pain, the majority of cells were empty or had just a few studies. Nurses in hospitals were the most widely studied group for shoulder pain, with a mean prevalence of 44%. Home health care may be slightly more risky for shoulder pain (35%), but limited studies may undermine the estimates. Similar trends were found for the neck, upper-extremity, and lower-extremity pain outcomes—lack of evidence in many cells, some trending to higher levels in home health care, and not a lot of consistent trends. Discussion

Given the studies on the reported prevalence of MSDs in nurses and nursing aides, it was apparent that high levels of pain were experienced over the course of a year, with the

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28 Month XXXX - Human Factors

Lower Extremity

Percentage of Populaon (%)

70 60 50 40

38

36 30

No Data

20

20

10 6

8

0

Lifeme

Annual

Current

3 to 6 months

MSD Injury

Lost Time Injury

Figure 5. Prevalence of lower-extremity pain as a function of pain outcome: lifetime, previous 12 months, current (less than 7 days), 3 to 6 months, musculoskeletal disorder injury, and lost-time injury.

highest levels in the lower back, shoulder, and neck areas. Although there is a critical mass of studies for these body regions and follow-up time frame, focusing on the yearly prevalence provides flawed representation of the pain and suffering for nurses as it does not capture the transient nature of pain. As our tracking systems and statistical procedures expand to handle big data, the capturing of instantaneous pain in these body regions may lead to a better understanding of the risk factors driving the injuries. One of the potential issues with nurses is that they have so many different risk factors they deal with on a given day, from interacting with sick patients to being on their feet for long periods to handling many materials (Poole Wilson, Davis, Kotowski, & Daraiseh, 2015). If one adds the mental and potential stress demands for a typical 12-hr shift, one has a complex set of risk factors that could all contribute to the pain suffered by the nurses. Obviously, many researchers (Bakker et al., 2009; Buckle, 1987; Kuiper et al., 1999; Nelson & Baptiste, 2006) have shown a link between low-back pain in nurses and patient handling,

which requires lifting and repositioning of heavy patients. Shoulder injuries and pain could potentially be related to the repositioning of the patient in the bed when the nurse leans over the bed and uses his or her upper body to slide a patient up in bed or turn the patient on his or her side; both are routine tasks performed by nurses (Poole Wilson et al., 2015). Although few study authors have investigated MSDs in upper and lower extremities, there are potentially many risk factors that may contribute to MSDs in the extremities, including standing and walking for long periods on hard surfaces or slips for the lower extremity and chart entry on electronic medical record devices and more-hand-intensive procedures to patient for upper extremity. However, the current review has focused on identifying the reported prevalence of adverse outcomes for nurses and cannot provide any direct insight into the underlying risk factors. One take-home message from the current review is that studies are limited in the types of MSD outcomes and facilities. Table 2 has too many empty cells or cells with only a single study to draw conclusions of the prevalence of

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29

Shoulder

Low back

Body Region

Mixed

Long-term care

Home health

Hospital

Mixed

Long-term care

Home health

Hospital

Facility

Nurses Nursing aides Mixed Nurses Nursing aides Mixed Nurses Nursing aides Mixed Nurses Nursing aides Mixed Nurses Nursing aides Mixed Nurses Nursing aides Mixed Nurses Nursing aides Mixed Nurses Nursing aides Mixed

Health Care Worker

52 (2) 60 (1)

30 (1)

66 (18) 58 (2) 77 (3)

Lifetime

51 (2)

48 (8)

38 (3) 27 (3)

31 (5) 24 (1) 36 (3)

22 (2)

53 (2)

43 (1)

48 (1) 38 (3) 28 (1)

21 (5) 34 (1) 68 (2) 18 (2) 61 (1) 55 (1)

39 (8)

55 (5) 33 (2)

34 (24)

Current

37 (2)

3 to 6 Months

33 (3)

35 (8) 53 (1) 66 (1) 73 (1)

53 (5) 19 (1) 50 (4) 44 (23)

55 (52) 40 (6) 65 (16) 40 (1) 62 (1) 59 (3) 42 (2) 38 (1)

Past Year

55 (1)

17 (1)

26 (1)

3 (1)

14 (1) 24 (3) 11 (4)

MSD Injury

(continued)

14 (9) 31 (2) 35 (1)     31 (1)   25 (3) 16 (1)   14 (1)   19 (2)   6 (2)                  

Lost-Time Injury

Table 2: Summary of the Mean Prevalence for Different Pain Outcomes as a Function of Health Facility and Health Care Worker (number of studies in parentheses)

30

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Mixed

Long-term care

Home health

Hospital

Facility

Mixed

Long-term care

Home health

Upper extremity Hospital

Neck

Body Region

Table 2: (continued)

Nurses Nursing aides Mixed Nurses Nursing aides Mixed Nurses Nursing aides Mixed Nurses Nursing Aides Mixed Nurses Nursing aides Mixed Nurses Nursing aides Mixed Nurses Nursing aides Mixed Nurses Nursing aides Mixed

Health Care Worker

Lifetime

24 (1)

25 (2)

45 (9) 27 (14) 30 (1) 25 (9)

57 (1)

59 (1) 63 (1)

41 (22) 12 (1) 40 (11)

Past Year

12 (1)

15 (1) 29 (2)

57 (2)

39 (1)

3 to 6 Months

21 (1)

14 (1) 6 (1)

14 (4)

24 (3) 17 (4)

11 (1)

29 (4) 23 (3)

45 (3)

27 (11)

Current

2 (1)

30 (2) 11 (2) 13 (1) 2 (1)

1 (1)

MSD Injury

(continued)

10 (1)   6 (2)                                          

Lost-Time Injury



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31

Facility

Note. MSD = musculoskeletal disorder.

Mixed

Long-term care

Home health

Lower extremity Hospital

Body Region

Table 2: (continued)

Nurses Nursing aides Mixed Nurses Nursing aides Mixed Nurses Nursing aides Mixed Nurses Nursing aides Mixed

Health Care Worker

Lifetime

34 (1)

43 (2)

35 (17) 30 (2) 38 (8)

Past Year

18 (1)

52 (2)

30 (1)

3 to 6 Months

21 (1)

15 (1) 10 (1)

18 (4)

24 (6)

Current

5 (1)

7 (2)

MSD Injury

     

8 (2)                

Lost-Time Injury

32 Month XXXX - Human Factors

many of the MSD outcomes for anything but low-back pain in hospitals. The bottom line is that because of the primary focus on low-back pain for nurses, researchers may be neglecting many of the other injuries that the nursing profession faces, and with new procedures and devices, these risk factors are likely to continue to change and impact different body regions. Another major conclusion drawn from the review was that few studies focused on more serious MSD outcomes, such as reported MSDs and lost-day cases. Although evaluating yearly pain is easier as one needs only a single survey, information about more serious cases is lost (Ferguson & Marras, 1997). Furthermore, the majority of the studies relied upon subjective assessments of pain (e.g., self-administered survey without clinical examination). The subjective nature of pain may be one underlying factor for the variability in prevalence of a specific pain outcome (as seen in Figures 1 to 5). Further, remembering episodes of pain over a long period (e.g., 12 months) can be highly subjective and person dependent, which may also contribute to the variability in prevalence across studies. The subjective nature of the pain assessments and long observation times make it difficult to identify the real casual factors for the injuries, especially in such a complex environment. Although patient handling is the big elephant in the room, many factors are likely to contribute to progression of MSDs in nurses. Reported prevalence values may also be a function of when the study was conducted. By scanning Table 2, one sees that authors of few studies (fewer than 21 studies) investigated MSD prevalence before 1994, but there is a steady trend in more studies in the past two decades (culminating with 14 studies in the past 12 months). By having more studies in recent years, the prevalence estimates may be more accurate to the current MSD trends in health care. Health care is constantly changing, with new practices and policies that will directly impact MSDs. A perfect example is the no-lift policies that will likely reduce low-back injuries, but shoulder injuries may start to increase as a result of pushing force when moving the lift-assist devices. In the future, researchers will need to prove this theory of more diverse types

of injuries. The bottom line is that the timing of the studies (date study collected) may have influenced the actual observed prevalence levels of the different MSD outcomes. Furthermore, these studies also represent the reported prevalence, which may not be a completely accurate estimate of the actual prevalence. There were some major voids in the understanding of musculoskeletal pain in the nursing profession. First, studies were extremely limited in the investigation of home health care and long-term care facilities, with fewer than five studies in a given pain outcome category. With the likelihood of increased demands in longterm care and home health care facilities, it will be imperative to have a better understanding of MSDs and pain in these facilities. Home health care introduces another dimension of ergonomic risk, with each house representing a unique set of exposures. Home health care needs to be a high priority in both understanding ergonomic exposures and developing flexible interventions that are drastically different from the traditional hospital settings. Second, few researchers have investigated the upper- and lower-extremity pain for most of the pain outcome variables. As the demands, processes, and utilization of lift equipment change, the prevalence of the pain in body regions other than the low back may increase. Finally, most studies have utilized subjective surveys to assess MSD pain, predominantly assessing yearly pain. As a result, the progression of MSDs from discomfort to disability has yet to be fully understood in the health care industry. Subjective assessments that have been predominantly conducted for 12-month retrospective periods are potentially biased, especially when determining association with exposures. In all, these voids indicate that there is a lot of work yet to be done in order to completely understand the exposures and resulting MSD outcomes in all types of health care facilities. Further, the bar will likely continue to change as health care evolves with different demographics (e.g., obesity and living longer) and processes. Worldwide MSD Pain

Another interesting summary of the studies was how MSDs and corresponding pain impact nurses and nursing aides across the different regions of

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MSD Pain in Nursing Workers

the world. For yearly prevalence, Australia/Philippines had the highest prevalence of low-back pain (71%), followed by Africa (64%) and the Middle East (58%). The rest of the regions (Europe, North America, South America, and Asia) had low-back prevalence between 51% and 57%. Yearly neck prevalence ranged between 37% (United States/ Canada) to about 48% (Middle East, Asia, South America, and Europe). Shoulder pain was greatest in Asia (52%) and Europe (50%) and lowest in Africa (31%) and North America (35%). Upperand lower-extremity pain was less than 30% in most regions, with the exception of the Middle East (45% for upper extremity and 52% for lower extremity). Overall, the North American region had the lowest prevalence rates, whereas the Middle East, Asia, and Australia/Philippines had the highest prevalence of yearly MSD pain across all body regions. Only one study has involved investigating pain for nursing in South America. A slightly different picture of musculoskeletal pain was reported for current symptoms. The Africa region had the highest prevalence for lowback pain (63%), followed by the United States/ Canada region (43%), Asia (32%), South America (34%), and Australia/Philippines (24%). Prevalence of neck pain was found to be lower than current low-back pain, with the highest levels in Africa (41% as reported in one study) and Europe (37%) and lowest in Asia (about 13%) and Australia/Philippines (about 20%). For current shoulder pain, Australia/Philippines (11%) had the lowest prevalence, whereas Europe (40%) and Africa (41%) were at the highest. The United States/Canada had a mean current prevalence of about 20%. Across the world, the number of studies on current upper and lower extremities was small, with most of them reporting below 15% to 20% for current pain. The only exception was one study in Africa (24% for upper extremity and 40% for lower extremity). For current pain, the general trend was that the lowest prevalence values were found in Australia/Philippines, whereas the highest values were in Africa. However, few studies have been performed in Africa. Although the current review cannot provide insight into underlying reasons for the differences between world regions, one may provide conjecture about the underlying factors. The

33

largest differences between regions were for low-back pain, whereby less developed countries had significantly higher prevalence levels. These regions also had the smallest number of studies, which may be reflective of some bias (e.g., overreporting in a few studies) or lack of infrastructure (e.g., limited use of lift-assist devices). Because the number of studies in a given region is liable to be directly related to the number of countries, the differences between developing and developed regions in low-back pain is likely due to better equipment and working environments. Future research with multinational investigators may shed more light into these differences. Many factors may contribute to the differences between world regions for the other body regions, with the most likely cause being different exposures during the treatment of patients. Another review of the actual exposures identified in different countries could provide valuable insight into what is driving the different prevalence levels. Future Impact of MSD in Health Care

With an increase in the number of facilities adopting “no-lift” policies, prevalence rates may be trending down for nurses and nursing aides. As the effectiveness of these programs increases due to improvements in leadership, training, and accessibility of equipment, prevalence of MSDs, specifically low back, will likely continue to decrease in health care facilities. However, MSDs in the shoulders and upper extremity may actually increase as the physical demands change from lifting patients to pushing lifting-assist devices and other medical equipment. For this reason, future epidemiological studies on pain and injuries in nurses and nursing aides will need to focus on shoulders and upper extremities and go beyond the traditional focus on the low-back region. Another major factor in future MSDs in health care could be the shift to early mobility whereby other health care providers besides nurses and nursing aides interact with the patient. Early mobility has increasingly become a responsibility of physical therapists (Perme & Chandrashekar, 2009). Physical therapists are required to handle patients with varying levels of physical function due to muscle atrophy,

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34 Month XXXX - Human Factors

disease or infection, or drug-induced delirium (Perme & Chandrashekar, 2009). Physical therapists may be the worker population that is at most risk in the near future as this integration of patient mobility becomes commonplace in all health facilities. To date, authors of few studies (seven studies) have investigated the prevalence of MSDs for physical therapists. In these studies, the MSD pain in the previous 12 months was lower for physical therapists than nurses: low back-pain at 39% versus 55%, shoulder pain at 14% versus 44%, neck pain at 20% versus 42%, upper-extremity pain at 20% versus 26%, and lower-extremity pain at 6% versus 36%, respectively (Bork et al., 1996; Campo, Weiser, & Koenig, 2009; Campo, Weiser, Koenig, & Nordin, 2008; Cromie, Robertson, & Best, 2000; Holder et al., 1999; Molumphy, Unger, Jensen, & Lopopolo, 1985). Other studies have shown similar relative values for lifetime pain (Cromie et al., 2000; Salik & Özcan, 2004). Limitations of Current Review

Although the review has provided potentially valuable insight into the prevalence of MSDs in nurses and nursing aides, several potential limitations need to be discussed. First, the review was for the most part inclusive of all the articles that evaluated prevalence of MSDs. We did use the MMAT (Pluye & Hong, 2014) to rate the quality of the articles, with the lowest-quality articles being eliminated from the review. Second, only articles published in English were included. This criterion may have resulted in some estimates being neglected in non-English-speaking countries. Third, the review concentrates on the health outcome and neglects the underlying risk factors. A complete understanding of the impact of MSDs on the nursing profession will require quantification of risk factors, which other reviews have done (Bakker et al., 2009; Buckle, 1987; Kuiper et al., 1999; Nelson & Baptiste, 2006). The current review complements these previous reviews by highlighting who is at risk of MSD injuries and pain and specifically for nurses and nursing aides. Finally, the current review concentrated on prevalence and not actual incidence rates. Obviously, injury rate would take into account the number of nurses or nursing aides who were

exposed to MSD risk factors. However, studies on incidence rates were more infrequent than those on prevalence (29 vs. 88, respectively), making it difficult to draw inferences with respect to health outcomes, especially when one starts to break prevalence rates down to the different types and body regions. Given these potential limitations, the review was robust in its inclusion criteria, which allowed for the identification of missing data for the English literature as a whole. Conclusion

Although MSD pain in the nursing profession appears to have been broadly investigated worldwide, there were several major voids in the literature. First, the majority of authors investigated MSD pain in nurses and nursing aides in hospitals. Few researchers have investigated MSD pain for nurses and nursing aides in home health care and long-term care facilities (fewer than five studies in a given pain outcome category). Second, few authors have investigated the upper- and lower-extremity regions for most of the MSD pain outcome variables. With changes in demands and expected increased usage of liftassist devices and other safe patient-handling equipment, it will be imperative to understand the pain and injuries in the extremities. Finally, most studies have utilized subjective surveys to assess MSD pain, predominantly in the previous year. Better clinical diagnoses will improve the understanding of MSD pain. Given many environmental and social changes in the health care industry, including living longer with more chronic diseases, bariatric patients, early mobility, and wanting to be at home during sickness, higher prevalence levels may shift to different populations—home health care and longterm care nurses—as well as in different body regions, such as shoulders and upper extremity. Future research will be needed to track these potential shifts in pain, away from a focus on low-back pain for nurses in hospitals. Acknowledgments Partial funding was provided by Hill-Rom, Inc., to conduct this literature review and provide a solid foundation for researchers investigating musculoskeletal disorders in health care.

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MSD Pain in Nursing Workers Key Points •• Authors of a majority of the studies investigated musculoskeletal disorder (MSD) pain in nurses and nursing aides in hospitals, whereas few studies have settings in home health care and longterm care facilities. •• Authors of few studies have investigated the upper- and lower-extremity regions for most of the MSD pain outcome variables. •• Most studies have utilized subjective surveys to assess MSD pain, predominantly in the previous year.

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Kermit G. Davis is an associate professor at the University of Cincinnati in the College of Medicine, Department of Environmental Health, where he also directs the Low Back Biomechanics and Workplace Stress Laboratory. He received his PhD in occupational ergonomics from The Ohio State University, College of Engineering, Department of Industrial and Systems Engineering. He is a certified professional ergonomist. Susan E. Kotowski is an assistant professor at the University of Cincinnati in the College of Allied Health Sciences. She is also director of the Gait and Movement Analysis Lab. She received her PhD in occupational ergonomics and safety from the University of Cincinnati, College of Medicine. She is also a certified professional ergonomist. Date received: December 10, 2013 Date accepted: March 20, 2015

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