Accepted Manuscript Title: Work-related psychosocial risk factors and musculoskeletal disorders in hospital nurses and nursing aides: A systematic review and meta-analysis Author: Dinora Bernal Javier Campos-Serna Aurelio Tobias Sergio Vargas-Prada Fernando G. Benavides Consol Serra PII: DOI: Reference:
S0020-7489(14)00297-1 http://dx.doi.org/doi:10.1016/j.ijnurstu.2014.11.003 NS 2471
To appear in: Received date: Revised date: Accepted date:
25-1-2014 31-10-2014 4-11-2014
Please cite this article as: Bernal, D., Campos-Serna, J., Tobias, A., VargasPrada, S., Benavides, F.G., Serra, C.,Work-related psychosocial risk factors and musculoskeletal disorders in hospital nurses and nursing aides: A systematic review and meta-analysis, International Journal of Nursing Studies (2014), http://dx.doi.org/10.1016/j.ijnurstu.2014.11.003 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Work-related psychosocial risk factors and musculoskeletal disorders in hospital nurses and nursing aides: A systematic review and meta-analysis Dinora Bernal1,2, Javier Campos-Serna
2,3,4
, Aurelio Tobias5, Sergio Vargas-Prada2,
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Fernando G. Benavides2,4, Consol Serra 2,4,6
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1. Faculty of nursing care University of Panama. Panama.
2. CiSAL - Center for Research in Occupational Health, Universitat Pompeu Fabra.
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Barcelona, Spain
3. Area of Public Health and Preventive Medicine, University of Alicante. Alicante,
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Spain.
4. CIBER Epidemiology and Public Health (CIBERESP). Spain.
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5. Institute of Environmental Assessment and Water Research (IDAEA), Spanish Council for Scientific Research (CSIC)
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6. Occupational Health Service, Parc Salut MAR. Barcelona, Spain.
Corresponding author: Consol Serra, Center for Research in Occupational Health – Universitat Pompeu Fabra. Carrer Doctor Aiguader 88, 08003-Barcelona, Spain. [
[email protected]] Phone: 0034-933160875. Fax: 0034-933160410
Keywords: Musculoskeletal
disorders,
Nurse,
Hospital,
Psychosocial
factors,
Workplace, Systematic review, Meta-analysis.
Word count text: 3309
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Work-related psychosocial risk factors and musculoskeletal disorders in hospital
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nurses and nursing aides: A systematic review and meta-analysis
What is already known about the topic
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Musculoskeletal disorders (MSD) are one of the leading causes of disability in hospital nurses and nursing aides. Traditionally, studies on risk factors for MSD have focused on physical activities like manual handling, and individual characteristics, such as sex and age. Recently, a growing body of evidence suggests that organizational factors might play an important role in the occurrence of MSD in nurses and aides. What this paper adds
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Despite the small number of longitudinal studies available, our findings provide consistent evidence of an association between exposure to work-related psychosocial factors and MSD in hospital nurses and aides. Interventions to reduce MSD in hospitals should take into account not only ergonomics, but also the improvement of organizational aspects of the work environment.
Abstract
Objectives: To estimate the association between psychosocial risk factors in the workplace and musculoskeletal disorders (MSD) in nurses and aides. Design: Systematic review and meta-analysis Data sources: An electronic search was performed using MEDLINE (Pubmed), Psychinfo, Web of Science, Tripdatabase, Cochrane Central Controlled Trials, NIOSHTIC and Joanna Briggs Institute of Systematic Reviews on Nursing and Midwifery, to identify observational studies assessing the role of psychosocial risk factors on MSD in hospital nurses and nursing aides. 2 Page 2 of 45
Review methods: Two reviewers independently assessed eligibility and extracted data. Quality assessment was conducted independently by two reviewers using an adapted version of the Standardized Quality Scale. Random-effects meta-analysis was
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performed by subsets based on specific anatomical site and the exposure to specific psychosocial risk factors. Heterogeneity for each subset of meta-analysis was assessed
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and meta-regressions were conducted to examine the source of heterogeneity among studies.
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Results: Twenty four articles were included in the review, seventeen of which were
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selected for meta-analysis. An association was identified between high psychosocial demands-low job control with prevalent and incident low back pain (OR 1.56; 95%CI
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1.22-1.99 and OR 1.52; 95%CI 1.14-2.01, respectively), prevalent shoulder pain (OR 1.89; 95%CI 1.53-2.34), prevalent knee pain (OR 2.21; 95%CI 1.07-4.54), and
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prevalent pain at any anatomical site (OR 1.38; 95%CI 1.09-1.75). Effort-reward
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imbalance was associated with prevalent MSD at any anatomical site (OR 6.13; 95%CI 5.32-7.07) and low social support with incident back pain (OR 1.82; 95%CI 1.43-2.32).
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Heterogeneity was generally low for most subsets of meta-analysis. Conclusion: This meta-analysis suggests that psychosocial risk factors at the workplace are associated with MSD in hospital nurses and nursing aides. Although most preventive strategies at the workplace are focused on ergonomic risk factors, improving the psychosocial work environment might have an impact on reducing MSDs.
Keywords: Musculoskeletal disorders, Nurse, Hospital, Psychosocial factors, Workplace, Systematic review, Meta-analysis.
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INTRODUCTION Work-related musculoskeletal disorders (MSD) are defined as symptoms caused or
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aggravated by occupational risk factors, including discomfort, damage or persistent pain in body structures, such as muscles, joints, tendons, ligaments, nerves, bones, and the
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circulatory system (Barboza et., 2008; Cherry et., 2001; Kee et al., 2007; Trinkoff et al.,
2002). MSD are the most common health problem associated with work in Europe,
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affecting millions of workers. It has been estimated that 25% of European workers
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complain of back pain and 23% of muscle aches. MSD are the main cause of sickness absence in western European countries (Murray et al.), and in the United States and
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Canada (Punnett et al., 2004). In Europe, costs due to MSD represent approximately 2 per cent of their Gross Domestic Product (GDP) (Bevan et al., 2009), without
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considering productivity losses and social costs (Choobineh et al., 2010; Menzel, 2007;
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Podniece et al., 2008). Furthermore, MSD is also one of the main causes of sickness absence among hospital nurses and nursing aides, although underreporting is common
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(Menzel, 2008).
Factors associated with MSD include individual characteristics, such as age and sex, occupational risk factors and non-work related exposures. Physical risk factors that arise from a worker’s tasks (e.g. physical demands, handling loads, repetitive movements or vibration) are well established workplace risk factors for the occurrence of MSD. However, there is some evidence that occupational psychosocial risk factors, such as high psychosocial demands, low job control or low social support, could also have a role (European Agency for Safety and Health at Work, 2007; Magnago et al., 2007). Hospital nurses and nursing aides are occupational groups especially at risk of developing MSD (Magnago et al., 2007; Solidaki et al., 2010). The prevalence of MSD
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in nursing professionals has been documented in different studies (Choobineh et al., 2010; Smith et al., 2003) and varies across countries (Coggon et al., 2013). Karahan et al found that hospital nurses and nursing aides had the highest prevalence of MSD
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(77.1%) in a sample of Turkish health care workers (Karahan et al., 2009). In Norway the prevalence of MSD in nursing aides has been found to be as high as 89% (Willy,
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2003), whereas in Japan it is much lower at around 37% (Matsudaira et al., 2011).
Several studies have shown a high risk of developing neck and low back pain in hospital
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nurses, attributed to both physical and psychosocial factors at work, such as shift work,
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long hours at work (Magnago et al., 2007; Menzel, 2007; Trinkoff et al., 2002) and the stress related to patient’s management (Solidaki et al., 2010).
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Although some previous systematic reviews have reported an association between psychosocial risks factors in the workplace and MSD in hospital nurses and nursing
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aides, to our knowledge no meta-analysis has yet been published. Thus, the aim of our
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study was to evaluate and quantify the association between exposure to psychosocial
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factors in the workplace and MSD in nurses and nursing aides in hospital settings.
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METHODS Search strategy
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An electronic search was carried out using MEDLINE (Pubmed), Psychinfo, Web of Science, Tripdatabase, Cochrane Central Controlled Trials, NIOSHTIC and Joanna
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Briggs Institute of Systematic Reviews on Nursing and Midwifery. Our search strategy was applied similarly to all databases and combined four blocks of keywords intended
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to capture different aspects of our review: 1) the outcome (prevalence and incidence of
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MSD), 2) the study population (nurses and nursing aides), 3) exposure (psychosocial risk factors, including high psychosocial demands/low job control, low social support
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and effort-reward imbalance), and 4) occupational setting (hospital). The search terms used were: for study population and occupational setting “((((("nurses"[MeSH Terms]
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NOT "breast feeding"[MeSH Terms] OR nurse[Text Word]) OR ("personnel,
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hospital"[MeSH Terms] OR hospital staff[Text Word])) OR aides[All Fields]) OR ("nursing staff"[MeSH Terms] OR "nurses"[MeSH Terms] OR nursing personnel[Text
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Word]))”; for psychological risk factors “(((("psychosocial factors"[All Fields] OR ("workplace"[MeSH Terms] OR workplace[Text Word])) OR (job[All Fields] AND ("sprains and strains"[MeSH Terms] OR strain[Text Word]))) OR ("social support"[MeSH Terms] OR social support[Text Word])) OR (("work"[MeSH Terms] OR work[Text Word]) AND ("organisations"[MeSH Terms] OR organisational[Text Word]) AND factors[All Fields])))”; and for MSD “(((((((musculoskeletal[All Fields] OR ("upper extremity"[MeSH Terms] OR upper limbs[Text Word])) OR "wrist injuries"[MeSH Terms]) OR ("elbow"[MeSH Terms] OR "elbow joint"[MeSH Terms] OR elbow[Text Word])) OR ("shoulder pain"[MeSH Terms] OR shoulder pain[Text Word])) OR ("neck pain"[MeSH Terms] OR neck pain[Text Word])) OR ("low back
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pain"[MeSH Terms] OR low back pain[Text Word])) OR ("back pain"[MeSH Terms] OR back pain[Text Word])). Also, the reference lists of papers which fulfilled our inclusion criteria were reviewed to identify additional studies not included in our
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electronic search. Study selection and eligibility criteria
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Observational studies (cohort, case-control or cross-sectional), published in English or Spanish between January 2001 and March 2014, were included if they assessed the
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association between MSDs and psychosocial risk factors at the workplace in hospital
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nurses and nursing aides. Studies were excluded if: i) they were in a different language than English or Spanish, ii) the study population was nursing students, or iii) a wide
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range of hospital workers and occupations were included, but data for hospital nurses or nursing aides were not analysed separately.
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After excluding duplicates, a total of 3202 citations were obtained from the electronic
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search. All citations were reviewed by title, and when was necessary, by abstract. Ninety-one potential publications were identified and for all of them full text were
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obtained. Those studies were reviewed by two independent researchers (DB and JC). The degree of agreement (kappa index) between the two reviewers was 80.2 %. Disagreements (20% of the 91 identified publications) were resolved by a third reviewer (SVP/CS) who made the final decision. Twenty-six publications (all in English) which met the inclusion criteria were included for quality assessment. Figure 1 shows the flow chart of study selection.
Quality assessment and extraction The methodological quality of the 26 studies that met the inclusion criteria was assessed independently by two reviewers (DB and JC). As has been done in previous systematic reviews for meta-analysis (Bongers et al., 2002; Gershon et al., 2007), we used an
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adapted version of the Standardized Quality Scale developed by van der Windt et al. (van der Windt et al., 2000). This scale included 15 items grouped into 5 areas: 1) study objective, 2) study population, 3) measurement of psychosocial exposure, 4) outcome,
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and 5) data analysis and presentation. Each item was rated as "positive" (when requirement was met), "negative" (when requirement was not met) or "unclear" (unsure
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if requirement was met). A score was obtained for each study by the sum of all positive responses (1 point each item). Studies were considered as high-quality when the score
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was higher than 80% of the maximum possible score, intermediate quality when the
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score was between 70% and 79%, and low-quality when it was below 70%. Two studies were of low quality, and were excluded (Dundar et al., 2010; Fonseca and Fernandez.,
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2010).
The following general and methodological information was obtained from each of the
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24 included papers (table 1): authors’ last names, country, year of publication,
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epidemiological design, study population, sample size, response rate, mean age, and work-related physical demands. Moreover, characteristics of the exposure to
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psychosocial risk factors (high psychosocial demands, low job control, low social support from co-workers and supervisors, and effort-reward imbalance) and information related to the outcome (prevalence of pain at any anatomical site, prevalence and incidence of back pain, prevalence of neck pain, prevalence of shoulder pain and prevalence of knee pain) were collected. Also, information about adjustment variables and epidemiologic measures of association (prevalence ratio (PR), hazard ratio (HR) or odds ratio (OR)), and their 95% confidence interval (95% CI) were identified from each paper. Meta-analysis
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From the 24 studies included in the review, we excluded for meta-analysis one study where the 95% CIs were not provided (Camerino et al., 2001), one cohort (Herin et al., 2011) and four cross-sectional studies (Carugno et al., 2012; Sorour and El-Maksoud.,
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2012; Surawera et al., 2013; Violante et al., 2004) where different psychosocial exposures and/or outcomes were assessed; and one cohort study because hazard ratios
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were reported as measures of association (Smedley et al., 2003). Therefore, 17 studies were considered for meta-analysis, which was carried out using version 11 of Stata
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software (StataCorp, 2009).
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Random effects models were estimated using the method proposed by DerSimonian and Laird (DerSimonian et al., 1986), and the included studies were grouped into nine
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subsets according to their epidemiological design, the type of psychosocial exposure (high psychosocial demands/low job control, low social support and effort-reward
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imbalance) and the main outcome (prevalent pain at any anatomical site, prevalent and
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incident back pain, prevalent neck pain, prevalent shoulder pain and prevalent knee pain). Forest plots of meta-analysis were depicted for each of the nine subsets of
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studies: (1) exposure to high demands/low job control with prevalence of low back pain; (2) exposure to high demands/low job control with prevalence of neck pain; (3) exposure to high demands/low job control with prevalence of shoulder pain; (4) exposure to high demands/low job control with prevalence of knee pain; (5) exposure to high demands/low job control with prevalence of pain at any anatomical site; (6) exposure to low social support with prevalence of pain at any anatomical site; (7) exposure to effort reward imbalance with prevalence of pain at any anatomical site; (8) exposure to high demands/low job control with incidence of low back pain; and (9) exposure to low social support with incidence of back pain. The outcome “pain at any
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anatomical site” was considered for studies where musculoskeletal pain was reported without distinguishing a specific anatomical site. A pooled effect size (OR) and its 95% CI were reported for each subset. The Cochrane
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Q test was used to test for heterogeneity and the I2 statistic (the percentage of the total variability between studies due to heterogeneity) to quantify it (Huedo-Medina et al.,
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2006). The I2 takes values between 0 and 100%, and a value of 0% indicates absence of
heterogeneity. I2 was interpreted based on Higgins and Thompson classification
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(Huedo-Medina et al., 2006); percentages of 25%, 50% and 75% were considered as
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low, intermediate and high heterogeneity, respectively. A cut-off of p≤0.1 was considered to determine if heterogeneity was statistically significant.
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Meta-regression
Meta-analysis regression (or meta-regression) is an extension to standard meta-analysis
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that investigates the extent to which statistical heterogeneity between studies can be
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attributed to one or more specific characteristics of the studies. A meta-regression was performed for those subsets where the heterogeneity was statistically significant.
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Sample size, response rate and mean age where considered as potential study characteristics that might partially explain most of the observed heterogeneity. Associations between those variables and outcomes (log OR) were evaluated in univariate meta-regression models.
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RESULTS Systematic review Of the 24 intermediate and high quality studies included in the review (table 1), 18 had
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a cross-sectional design (Alexopoulos et al., 2003; Alexopoulos et al., 2009; Bos et al., 2007; Carugno et al., 2012; Choobineh et al., 2010; De Souza Magnago et al., 2010;
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Golabadi et al., 2013; Hoe et al., 2011; Menhrdad et al., 2010; Sembajwe et al., 2013; Simon et al., 2007; Smith et al., 2006; Sorour and El-Maksoud., 2012; Stone et al.,
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2007; Surawera et al 2013; Violante et all., 2004; Warming et al., 2009; Weyers et al.,
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2006) and 6 were prospective cohort studies (Alexopoulos et al., 2006; Camerino et al., 2001; Herin et al., 2011; Smedley et al., 2003; Smith et al., 2004; Yip, 2002).
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Most studies (n=11) were conducted in European countries, those that were not, came from Iran (3), Australia (2), China (2), Brazil (1), Egypt (1), United States (1), and Brazil
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and Italy (1). The number of participants in the included studies ranged from 58 to
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16,670, and most of them were women (90%), with an overall mean age that ranged between 27 and 44 years-old. Sixteen studies focused on nurses, and 8 studies recruited
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both nurses and aides. Different instruments were used to assess MSD and psychosocial risk factors. Most studies (70%) used the Standardized Nordic Questionnaire to measure MSD. Psychosocial risk factors were measured by the Karasek Job Content (JCQ) questionnaire, or an adapted version (Camerino et al., 2001; Carugno et al., 2012; Hoe et al., 2011), the Effort Reward Imbalance (ERI) questionnaire and the Copenhagen Psychosocial Questionnaire (COPSOQ). Furthermore, 13 studies were classed as “high quality” (with a score above 80% of the maximum possible score), and 11 were considered as “intermediate quality” as their score ranged between 76.9% and 78.6%. Meta-analysis
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Pooled risk estimates and heterogeneity values for each subset of studies are summarised in table 2. Statistically significant associations were found for high demands/low job control with the prevalence of low back pain (OR 1.56; 95% CI 1.22-
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1.99) and the incidence of low back pain (OR 1.52; 95% CI 1.14-2.01). Exposure to high demands/low job control was also associated with the prevalence of shoulder pain
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(OR 1.89; 95% CI 1.53-2.34), knee pain (OR 2.21; 95% CI 1.07-4.54) and pain at any anatomical site (OR 1.38; 95%CI 1.09-1.75), respectively. Likewise, low social support
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was significantly associated with the incidence of back pain (OR 1.82; 95% CI 1.43-
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2.32), and a strong association was observed between effort-reward imbalance and the prevalence of pain at any anatomical site (OR 6.13; 95% CI 5.32-7.07). In two cross-
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sectional subsets of meta-analysis heterogeneity was classed as moderate, and in one subset of cross-sectional studies heterogeneity was considered high (table 2). Due to the
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maximum number of tables and figures allowed, only forest plots of 3 subsets of cross-
the manuscript.
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Meta-regression
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sectional studies (figures 2-4) and 1 subset of cohort studies (figure 5) were included in
The three subsets of studies where heterogeneity was high (i. high psychosocial demands/low job control with the prevalence of low back pain) or moderate (ii. high psychosocial demands/low job control with the prevalence of neck pain; and iii. low social support with the prevalence of pain at any anatomical site) were considered for meta-regression. Only the variable “sample size” partially explained the high and moderate
heterogeneity
found
in
subsets
(i)
and
(ii)
(data
not
shown).
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DISCUSSION According to our findings, work-related psychosocial factors seem to be associated with
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MSD in hospital nurses and nursing aides. Specifically, exposure to high demands/low control, effort-reward imbalance and low social support were found to be associated
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with low back, neck, shoulder, upper extremity, knee, and/or pain at any anatomical site, either in nurses, aides or both.
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To our knowledge this is the first meta-analysis that explores the association between
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the exposure to psychosocial factors in the workplace and MSD in nurses and nursing aides who work in hospitals. All included studies used validated instruments to assess
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the exposure of psychosocial risk factors at work, based on well-established models among the scientific community, which have been widely used in previous studies. In
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addition, to assess MSD, most of the studies used the validated and widely used Nordic
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questionnaire (Kuorinka et al., 1987). It might be argued that self-reporting of workers' perception could be a source of bias. However, self-rated health is considered a good
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indicator of health status (Kaplan et al., 1996; Palmer et al., 2008). The quality assessment of the included studies was based on validated scales previously used in other published systematic reviews (Bongers et al., 2002;Alexopoulos et al., 2006; Yip, 2002).
Against these strengths, some limitations need to be addressed. Most of the included studies in our meta-analysis were cross-sectional and therefore, reverse causality cannot be ruled out. Another important limitation is that we used random effects models, assuming that the included studies were representative of the hypothetical population of studies, and that heterogeneity among the studies may be represented by a single variance granting too much weight to studies with small sample size. Likewise, it is
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possible that studies without positive or statistically significant findings may be less likely to be published by journals. For each subset of meta-analysis we assessed the possibility of publication bias by using Begg’s test (Palma Pérez et al., 2006). However,
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the potential risk of publication bias was quite low (data not shown). Furthermore, our systematic review and meta-analysis included predominantly nurses. Thus, it is possible
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that findings, such as the association between job control and musculoskeletal pain,
would have been different in a population largely consisting of nursing aides. Finally,
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the Standardized Quality Scale used to evaluate the quality assessment of the identified
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studies does not include the assessment of bias. This is a systematic review of observational studies about psychological risk factors at work; therefore, the possibility
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of selection bias cannot be dismissed.
The prevalence of low back pain in hospital nurses and nursing aides is very high, and it
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is the leading cause of sickness absence in this occupational group (Maul et al., 2003).
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Low back pain has been a subject of extensive research and is traditionally attributed to high physical demands (Harcombe et al., 2010; Menzel, 2004). However, the benefits
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from interventions (training or mechanical aides) to reduce physical demands and prevent low back pain have been small and of uncertain cost-effectiveness (Verbeek et al., 2011). A systematic review suggested that other underlying occupational and individual risk factors may contribute to the occurrence of low back pain in workers exposed to heavy manual handling (Punnett and Wegman, 2004). Among other potential occupational risks, work-related psychosocial factors, such as high job demand, low job control, low social support and effort-reward imbalance might have a role in the prevalence and incidence of low back pain in nurses and nursing aides. A systematic and critical review of cohort studies performed by Hartvigsen et al., did not find an association between work organisational factors (such as social support) and low
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back pain (Hartvigsen et al., 2004). These findings are contrary to what we found in our systematic review. However, the Hartvigsen review included a wide variety of occupations, and used an evidence synthesis instead of meta-analysis. Likewise, it is
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possible that due to the subjective nature of musculoskeletal symptoms, the definition of outcomes varied among studies. Also, the definition of psychosocial factors and the way
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these variables were collected varies. Therefore, it is possible that differences in the “case definition” might explain, at least partially, the lack of comparability and the
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contradictory findings between both reviews. Despite the small number of cohort
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studies included in our meta-analysis, they provided consistent evidence of an association between exposure to work-related psychosocial risk factors and MSD in
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hospital nurses and nursing aides. Some mechanisms might explain this. Ando et al proposed that workers exposed to high time pressure to meet demands at work, lack of
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social support and other organisational deficiencies, could increase the number of
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repetitive movements and also be predisposed to unhealthy awkward postures at work (Ando et al., 2000). Moreover, exposure to high time pressure could also increase
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workers’ mechanical work-load, which can produce muscular strain. This, in turn, may generate pain or exacerbate pre-existing pain (Ando et al., 2000). Due to the strong relationship between physical demands at work and MSD, it has been suggested that physical demands at work must be taken into account when analysing the relationship between work-related psychosocial risk factors and MSD (MacDonald et al., 2001). In fact, most of the studies included in our meta-analysis considered physical demands in their analysis as a confounding factor. Only three did not incorporate physical demands as a confounder (Sembajwe et al., 2013; Mehrdad et al., 2010; Stone et al., 2007). We conducted the meta-analysis with and without these three studies, and findings did not change significantly. Our meta-analysis results suggest a strong association between
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work-related psychosocial risk factors and the occurrence of MSD, even after adjustment for exposure to physical demands. In conclusion, our results provide consistent evidence of an association between
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exposure to work-related psychosocial risk factors and MSD in hospital nurses and aides. Nevertheless, future studies should use longitudinal designs to undertake more
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accurate assessments of exposure to work-related psychosocial risk factors that might have a strong impact on workers' health. Finally, interventions are needed to evaluate
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the effectiveness of preventive strategies to reduce the occurrence of MSD in hospital
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nurses and nursing aides. These interventions should take into account not only ergonomics, but also the improvement of organisational aspects of the work
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environment.
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Sources of funding This study has been funded by the fellowship project Erasmus - Eracol, University of
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Panama and the Center for Research in Occupational Health (CiSAL), Universitat
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Pompeu Fabra (Barcelona, Spain).
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Figure(s)
Records identified through database searching (n = 5,788 )
Additional records identified through other sources (n = 6)
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Records after removal of duplicates (n =3,102 )
Not relevant (n= 2,924) Review (n = 87)
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Full-text articles assessed for eligibility (n =91)
cr
Excluded based on title or abstract (n=3,011):
Excluded (n = 65):
an
ed
M
Studies included in qualitative assessment (n = 26)
Other occupation than nurse (n=16) Nursing students (n=1) Not measuring association between MSD and psychosocial factors (n=34) Setting not hospital (n= 14)
Ac
ce pt
Studies included in the review (n = 24)
Excluded (n = 2): Low quality (score