The physical workload of nursing personnel: association with musculoskeletal discomfort
Introduction
Direct care nursing personnel around the world report high numbers of work-related musculoskeletal disorders (Menzel, 2004). In the United States (US), nursing assistant (NA)1 and registered nurse (RN) are among the ten occupations reporting the greatest number of nonfatal musculoskeletal disorders resulting in days away from work (US Bureau of Labor Statistics, 2003). Most of these work-related musculoskeletal disorders (WMSDs) among nursing personnel are back injuries, although they also include neck, shoulder, arm, wrist, and knee disorders (Daraiseh et al., 2003). For direct care nursing staff, manual patient handling (moving or repositioning a patient using their own body strength) is the major cause of these injuries (Harber et al., 1985; Hollingdale, 1997; Knibbe and Friele, 1996; Smedley et al., 1995). After such an injury, many health care workers leave the field, either temporarily or permanently (Helminger, 1997; Lewis, 2002).
One of the major difficulties in reducing WMSDs is the multifactorial etiology, with many associated causes, including physical, work organizational, psychosocial, individual, and sociocultural factors (World Health Organization, 1985; US Department of Health and Human Services, 1997; National Research Council, 2001). The position of the US Occupational Safety and Health Administration (OSHA) is that physical risk factors alone are necessary and sufficient to produce WMSDs, that these physical risk factors exert more influence than other risk factors, and that reducing them reduces the incidence of WMSDs (US Department of Labor, 2000). However, unlike Great Britain's Health and Safety Executive, which passed Manual Handling Operations Regulations in 1992, OSHA's attempt to regulate workplace lifting in the US was overruled when Congress rescinded OSHA's ergonomics standard in early 2001.
For nursing personnel, there are several individual patient-handling tasks that are considered high-risk for producing WMSDs, such as turning, bathing, or dressing a patient, pulling a patient up in bed, and transferring a patient from bed to stretcher or bed to chair or toilet and back again (Garg et al., 1992; Nelson et al., 2003). Other risk factors for WMSDs in health care include weight of patients being moved or lifted, frequency of handling and moving patients, and level of postural awkwardness required by a task, particularly tasks with longer durations (Garg et al., 1991; Owen and Garg, 1991; Owen et al., 2000-2001; Smedley et al., 1995; Stobbe et al., 1988; Winkelmolen et al., 1994; Zhuang et al., 1999). Patient assistance or resistance can change the level of risk associated with a given task (Love, 1997). Some patient-handling and movement tasks present a risk to caregivers every time they perform them (e.g., lifting the torso of a patient to a sitting position on the edge of the bed, transferring a patient from bed to chair or chair to chair) (Zhuang et al., 1999; Marras et al., 1994), while with other tasks the risk builds over time through cumulative trauma (e.g., forward flexing while preparing to apply a sling or harness to a patient) (Daynard et al., 2001). Against the background of a growing obesity epidemic in the US population (US Department of Health and Human Services, 2004), the risk to direct-care nursing personnel from manual handling increases.
To assess the risk for incidence of WMSD, it is important to identify the most hazardous nursing tasks. In a study of models predicting overexertion injuries resulting from manual handling, Herrin et al. (1986) found that the most stressful tasks in a job were the most predictive of WMSDs. They concluded that aggregating highly stressful and less stressful tasks obscured important differences in predictive ability.
It has been suggested that there is a link between time pressure (an indicator of insufficient staffing resources) and musculoskeletal injuries (Bongers et al., 1993). Larese and Fiorito (1994), for example, found that nurses on units with high patient-to-nurse ratios (e.g., 12 patients to 1 caregiver) had more back pain and injuries than those who worked on units with lower ratios (e.g., 4 patients to 1 caregiver). Owen et al. (2000-2001) reported that nursing personnel identified insufficient staffing as one factor that increased the stress of manual handling by increasing the patient-to-nurse ratio and thereby increasing the frequency of lifts per caregiver per shift.
While individual hazardous nursing tasks have been identified (Garg et al., 1991; Love, 1997; Marras et al., 1999; Nelson et al., 2003; Zhuang et al., 1999), there are limited studies that quantify the frequency of high-risk tasks performed over time (Myers et al., 2002). Such studies must take into consideration variables that affect per-hour manual handling tasks. These include job classification, the weight of patients handled or moved, the patients’ dependency level, availability of patient handling equipment, and patient-to-nurse ratios. The purpose of this study, therefore, was to (1) quantify the high-risk tasks and associated factors that comprise the manual handling workload of nursing personnel over a 7-day period and (2) assess the association between the manual handling workload of nursing personnel and self-reported musculoskeletal discomfort.
Section snippets
Study design
We devised a cross-sectional study design to examine the association between high-risk patient-handling tasks and musculoskeletal discomfort in nursing personnel. Pain and discomfort may be the first indications of WMSDs (National Research Council, 2001). Therefore, the dependent variables were frequency and severity of musculoskeletal discomfort. The independent variables examined were frequency of performance of high-risk patient-handling tasks per hour worked, job classification, patient's
Musculoskeletal discomfort
Sixty-two percent of the subjects experienced discomfort at or above the moderate severity level in at least one body part in the 7 days prior to questionnaire completion. Surprisingly, there was no significant difference in the prevalence of musculoskeletal discomfort between nursing personnel who worked on high- versus low-risk units (66% versus 57%). Furthermore, age was not correlated with prevalence of musculoskeletal discomfort. However, the prevalence of musculoskeletal discomfort was
Discussion
The age and gender distribution of the sample reflected the nursing staff demographics at the facility as well as national demographics for US nurses (i.e., nurses are primarily over the age of 40 and female) (US General Accounting Office, 2002). The majority of study subjects (64%) were drawn from high-risk units. Propensity to volunteer may have been related to the degree of musculoskeletal discomfort the staff member was experiencing, which could have produced a biased sample. However, there
Conclusions and recommendations
Although the cumulative workload of highest-risk patient-handling tasks did not explain the variation in back pain among caregivers in this sample, there was an association with knee and wrist pain. With the introduction of new lifting technology and the increase in weight of US patient populations, WMSDs in those body parts among nursing personnel may rise. Previous prevalence rates for hand/wrist pain in nurses range up to 14% and for knees up to 20% (Daraiseh et al., 2003). Lifting equipment
Acknowledgements
This study was conducted as part of a doctoral dissertation at the College of Public Health, University of South Florida. This material is the result of work supported with resources from and the use of facilities at the James A. Haley Veterans Administration Medical Center in Tampa Florida, US Grant Sponsor: Centers for Disease Control and Prevention/ National Institute for Occupational Safety and Health; Grant No. T42-CCT412874. The contents are solely the responsibility of the authors and do
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