Reducing the incidence of back pain:
student nurses’ recommendations
Abstract
National Back Care week (3–9 October 2009) embraced the
promotion of back care. However, over a decade has pasted since the
RCN Safer Patient Handling campaign (1996), and reports continue
to highlight the high incidence of back pain within the nursing
profession. This article reveals student nurses’ experiences of back pain
and their recommendations to reduce the incidence of back pain in
the workplace. Statistics by the Department of Health (2002) report
24% of NHS staff experience back pain, reflecting the high prevalence
of this study, where 34% of student nurses experience back pain
during their clinical placement. The student nurses’ recommendations
clearly underpin the evidence-based research previously published, and
as our future workforce the student nurses’ voices need to be heard.
Key words: Back pain n Occupational health n Student nurses
n Workplace safety
N
ational Back Care week (3–9 October 2009)
embraced the opportunity of promoting awareness
of those who suffer from back pain, and what can
be done to treat and prevent it. According to the
Health and Safety Executive’s Chief Executive, Geoffrey
Podger, (2007):
‘Surprisingly, back pain will affect as many as
four out of five people in Britain, and results in
4.5 million days off work a year. Employers are
losing up to £335 million a year, but the biggest
losers are the millions of us who will have our
lives blighted by the condition.’
Back pain has been a major cause of health problems
for nurses and midwives. This concerns individuals and the
profession as a whole, especially with regard to costs incurred
by the NHS due to sick leave, replacement staff, wastage from
the profession and the increasing number of personal injury
claims (Snell, 1998). In exploring pre-registration student
nurses’ back pain, this study discovers their experience of
back pain and their recommendations of how to reduce back
pain incidence in the workplace.
Abbie Franklin Barnes is Nurse Lecturer, Keele University and
Registrant Panellist for Nursing Midwifery Council Investigating
Committee
Accepted for publication: October 2009
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Abbie Franklin Barnes
Back pain and nursing: 1996–2009
Back pain is a symptom not a diagnosis. It is not possible in
most cases to identify the structure that is causing the pain
by clinical examination (May, 2005). Radiographs, magnetic
resonance imaging and computer-assisted tomography may
be effective at identifying changes and abnormalities from
‘normal’ anatomy. Most cases of low back pain are known as
‘non-specific’ because they are not caused by serious damage
or disease, but by sprains, muscle strains, minor injuries or a
pinched or irritated nerve (NHS Choices, 2009).
Low back pain affects approximately one-third of the UK
adult population each year. Of these, around 20% (1 in 15 of
the population) will consult their GP about their back pain
(Macfarlane et al, 2006). This results in 2.6 million people in
the UK seeking advice about back pain from their GP each
year (Critchley and Hurley, 2007).
Back pain frequently starts for no apparent reason or
after an everyday activity, and recovery (or lack thereof)
is also frequently unpredictable. The vast majority of
people have no specific diagnosis or reason for their
back pain. It is often said that most people’s pain resolves
within 6–8 weeks, and only 15–20% develop chronic pain
(Critchley and Hurley, 2007).
The RCN Safer Patient Handling campaign was launched
in April 1996 to highlight the need to avoid the manual
lifting of patients in all but exceptional or life-threatening
situations. Instead, nurses should be given access and training
to appropriate equipment, and learn to evaluate and eliminate
manual handling situations by risk assessments.
Over 10 years have passed since the campaign was
launched, yet reports continue to show a high incidence of
back pain and injury sustained by nurses through the manual
handling of patients. The RCN (1993) developed the Code
of Practice for the Handling of Patients, subsequently revised in
1996 as the Code of Practice for Patient Handling (RCN, 1996a).
Its original recommendations specified that two nurses under
ideal conditions should lift no more than 50.8 kg. Turner
(1993) suggested that this figure was based on the lifting
capacity of men, and should be reduced to 31.75 kg for
women. Tarling (1992) and Macfarlane (1995) suggested that
most adults are too heavy or too large to be lifted manually,
and ultimately, Larcombe (1993) proposed that nurses should
be trained how not to lift patients manually.
Subsequently, the RCN (1996b) launched a campaign to
encourage employers to ensure nurses avoid lifting patients
manually, in all but exceptional circumstances. This campaign
reflects the debate that nurses’ prevailing cause of morbidity
is back pain (Stubbs et al, 1981; Confederation of Health
British Journal of Nursing, 2009, Vol 18, No 21

Service Employees, 1992; Newman and Callaghan, 1993;
Smedley et al, 1995), and the principle cause to be lifting
patients (Stubbs et al, 1981; Gladman, 1993; Newman and
Callaghan, 1993; Smedley et al, 1995). The most common
work-related illnesses in the NHS are musculoskeletal
disorders and stress (Department of Health [DH], 2002;
Health Commission, 2004). The DH has reported that 24%
of NHS staff regularly experience back pain (DH, 2002).This
is a particular risk for nurses, 80 000 of whom hurt their back
each year (Seccombe and Smith, 1996).
Moving and handling is considered to be an important
contributing factor to back pain. Moving and handling
related incidents make up approximately 17–18% of
reported incidents or accidents in the NHS (NAO, 2003)
and they account for 40% of NHS sickness absence costs,
estimated to be £400 million a year (DH, 2002). Nursing
students are at risk of developing musculoskeletal problems
during their education. Studies have shown that about 40–
60% of nursing students report musculoskeletal problems
at some stage during their education (Klaber-Moffett et
al, 1993; Smith et al, 2003). It has been shown that these
problems coincided with time spent working on wards,
where tasks such as lifting and handling patients were
frequent (Klaber-Moffett et al, 1993).
Kneafsey and Haigh’s (2007) study reported 26% of
the total sample (n=110) said they had begun to develop
musculoskeletal pain since becoming a student nurse.
Forty-eight per cent stated that this was caused by an
incident while on a placement. Inadequate patient handling
practices threaten student nurse safety in clinical settings.
Although some students may be overly confident, they
should be supervised when undertaking moving and
handling activities (Kneafsey and Haigh, 2007). Kneafsey
and Haigh (2007) conclude university-based moving and
handling education will only be beneficial if students learn
in clinical settings to take safe patient handling seriously.
Examples of poor practice set the context for the students’
experiences, and influence their compliance with poor
practice (Cornish and Jones, 2009).
Kneafsey’s (2007) further research highlights the importance
of a joint approach to education for safe moving and handling
between universities and Trusts. Consistent approaches must
be taught in both settings, and mentors need to be aware of
students’ learning needs, taking care to ensure that knowledge
underpinning clinical decision-making is transparent.
Cornish and Jones’ (2007) study found 71% of student
nurses had been asked to participate in a manoeuvre that
they thought was wrong and a similar number had been
asked to physically lift patients without using recommended
equipment. Perceived injuries to both staff and patients
were also described.
Student nurses’ experience of back pain
The author has been a nurse lecturer for nearly a decade
and heavily involved in moving and handling training for
student nurses. Predominately working at the University of
Wolverhampton, the author has discussed issues with students
surrounding moving and handling, and their experiences in
the workplace. The issues these conversations raised have
British Journal of Nursing, 2009, Vol 18, No 21
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EDUCATION
remained constant over the years, and out of professional
curiosity the author decided to ask the students to complete
a voluntary questionnaire.
The study is a small-scale explorative study, which uses
a convenience sample of third-year student nurses studying
at one university. Data were collected via a voluntary
questionnaire. The study was designed to investigate the
incidence of back pain for student nurses in clinical practice.
The study used a wide-aged sample of pre-registration
adult, child and learning disability branch: diploma and
degree student nurses. The questionnaire was distributed to
110 student nurses; 103 were returned, providing a response
rate of 94%. The questionnaire established their experiences
of back pain when on their clinical practice placement, and
how they would reduce the incidence of back pain in the
workplace. The student nurses’ clinical placements are in
a wide geographical area across the West Midlands region,
ranging from private healthcare organizations to the NHS.
Interestingly, 26% (n=27) of student nurses suffered from
back pain prior to commencing their nurse education
training, which reflects the UK lifetime prevalence of at least
60%, the fact that 40% of all adults have back pain in a single
year, and about 20% have back pain at any one point in time
(Walsh et al, 1992; Papageorgiou et al, 1995; Hillman et al,
1996; McKinnon et al, 1997; Waxman et al, 2000).
The high prevalence of back pain in the nursing profession
has frequently been associated with handling patients
(Seccombe and Ball, 1992).These findings have been available
for over a decade, but the problem continues with little or no
evidence that the situation has at all improved.Thirty-four per
cent of student nurses (n=35) experience back pain during
their clinical placement, but only 20% (n=21) of student
nurses officially reported their pain. It is well documented
that occupational physical stresses during work consist of
heavy or frequent lifting, whole body vibrations, prolonged
or frequent bending or twisting and postural stresses (high
spinal load or awkward postures). These biomechanical risk
factors have been identified consistently across many studies
(Bombardier et al, 1994; Frank et al, 1996; Burdorf and
Sorock, 1997; Ferguson and Marras, 1997; Hoogendoorn et
al, 2000; Vingård and Nachemson, 2000).
Research shows that the majority of people with back pain
do not seek any treatments, but cope by themselves (Walsh et
al, 1992; Waddell, 1994; Hillman et al, 1996; McKinnon et al,
1997).The present study highlights that 11% of student nurses
experience back pain during their clinical practice placement
due to moving and handling patients, the student nurses are
reluctant to take time off sick, the alternative is to self-treat
their back pain with rest, heat rubs and pain killers: analgesics
and anti-inflammatory medication. Out of the 34% of student
nurses that experienced back pain, 23% reported and phoned
in sick to their placement area; however, 11% continued to
work on placement, self-treating their back pain.
Evidence suggests that nurses regularly perform the assisted
sit-to-stand technique from a seated position approximately
90 times a day (Medical Devices Agency [MDA], 2002). Yassi
et al (2001) suggest the use of handling equipment can reduce
the risk of injury. Keir et al (2004) also advise the use of
equipment to relieve some of the physical burden of manual
1335

Box 1. Four reasons for resisting change
• Self-interest: people resist change if they perceive that they may lose out in some
way, for example loss of power or loss of input in decision-making, e.g.
‘I’ve done this for years and I don’t have a back problem’
• Misunderstanding and lack of trust: creation of safer working systems can be
negatively received, e.g. the following responses heard in the workplace, ‘If we
use hoists it becomes impersonal’ or ‘Now with all this equipment they will ask
us to do more work on our own’
• Different assessment or expectations: if the change is seen to be beneficial to the
management structure and add further work pressures to staff then there is likely
to be little cooperation with change process
• Low tolerance for change: staff exhibit signs of change fatigue and staff consider
that change is for change sake and there is little benefit to the staff or people
receiving care
From: Kotter and Schlesinger (1979)
Box 2. Minimizing the resistance of change
• Legal argument – raising the profile of The Health and Safety at Work Act 1974;
Human Rights Act 1998; Manual Handling Operations Regulations 1992
• Ethical argument – raising awareness of hazards in the workplace about regional issues
in the area, looking at recent local case studies and highlighting areas of concern
• Financial argument – the financial cost of implementing change into the workplace,
and the importance of this change being successful to the whole organization
• Evidence argument – application of ergonomics, knowledge gained from
biomechanics and physiology
• Professional argument – all professional bodies and organizations that support
handlers in health and social care set out professional guidance and information that
assists the development of safer systems for moving and handling
From: Fray (2005)
handling. The increased use of equipment and other aids
is regulated by the Provision and Use of Work Equipment
Regulations 1992 (PUWER Regulations 1992). This states
there is an absolute duty by the employer to ensure that work
equipment is constructed or adapted, and the equipment
is suitable and fit for purpose. Furthermore, the Lifting
Operations and Lifting Equipment Regulations (LOLER)
(Health and Safety Executive, 1998) imposed very detailed
duties on employers.
Student nurses’ recommendations of how to
reduce the incidence of back pain
The student nurses’ recommendations suggest adherence
to local Trust policy, and using evidence-based techniques
when handling people, and 70% of student nurses felt
this would prevent back pain in the clinical placement
areas. An employee owes a duty to the employer to
obey reasonable care and skill. This failure to perform as
trained or instructed could render the employee liable to
disciplinary proceedings, and nurses who put themselves
at risk of injury when safe practice is not promoted
incontestably arbitrate their autonomy as a practitioner.
The Nursing and Midwifery Council (2008) requires
nurses to promote and protect the interests and dignity of
others. This is a professional prescription, and has a robust
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theoretical basis, whereas respect for one’s own dignity is
given less attention.
All professional bodies in the health and social care setting
support the safe systems of work, and according to Fray
(2005) the development of safe systems of work in the
moving-and-handling field needs to consider ergonomics,
risk assessment and handling problems. ‘The provision of
improved equipment and the development of better hoists
and slings are successful interventions to reduce the risk
to handlers from moving people in the workplace,’ says
Fray (2005: p31). Twenty-seven per cent of student nurses
recommend suitability of equipment, and equipment that is
fit for purpose would significantly reduce the incidence of
back pain in the workplace.
Non-compliance of staff with the safe practice in patient
handling has been debated in the literature, and 34% of
the student nurses in this study experience back pain
during their clinical placement and state the cause of this
pain was due to patient handling (see Figure 1). Staff non-
compliance needs serious consideration; 64% of student
nurses felt that staff compliance with safe handling of people
techniques, set out by The Guide to The Handling of People
(Smith, 2005), would prevent back pain in the workplace.
However, one underlying factor hinders this: backache
is still often considered to be just part of the job (Owen,
1999). Furthermore, the problem lies with modern training
programmes which need to promote non-lifting methods,
but transferring these skills from classroom to the clinical area
can be difficult to implement.
A further recommendation by 22% of the student nurses is
that regular moving and handling training could prevent back
pain in the workplace. This is clearly stated by the National
Back Exchange Training guidelines (2002); and guidance
from the Royal College of Nursing, the Chartered Society
of Physiotherapy and the Health and Safety Commission
recommend that update training is required at least on an
annual basis. The Health Safety at Work Act 1974 imposes
a duty on every employer with regard to the handling of
people. These are defined in section 2(2)c: instruction and
training. Failure to comply with section 2(2)a–e under
the Health and Safety at Work Act 1974, can give rise to a
criminal conviction prosecution.
Barriers and recommendations of how
to reduce the incidence of back pain
The literature provides evidence that training and education
alone have no impact on working practice (Hignett et
al, 2003). Evidence suggests that in hurried and awkward
situations handlers may revert to methods they are familiar
and comfortable with, despite knowing that they are not
recommended practice. Some handlers prefer to rely on these
familiar techniques, or they believe them to be best practice
(Ruszala, 2005).
The patient handler may not perceive that there is
indeed a problem to be resolved, and therefore the patient
with handling needs is perceived as a low risk. The patient
handler may be regressing and/or maintaining a novice level
of proficiency and practicing within their comfort zone,
reluctant to embrace and develop their handling skills to
British Journal of Nursing, 2009, Vol 18, No 21

move up the scale from novice to expert (Benner, 1984).
The importance of role models is well documented (Salemi
et al, 2002; Lankford et al, 2003). Active involvement and
encouragement from key staff members may help to promote
and sustain behavioural change in healthcare settings (Cole,
2008). By contrast, negative role models can be influential
and poor practice learnt (Lankford et al, 2003).
This resistance to change practice manifests itself for four
distinct reasons: self-interest, misunderstanding and lack of
trust, different assessment or expectations, and low tolerance
for change (Kotter and Schlesinger, 1979) (see Box 1). One
to promote effective change is education, informing patient
handlers about why practice needs to change, in order to
overcome the rituals of nursing practice and the familiar
phrase: ‘We’ve always done it this way.’ Fray (2005) suggests
approaches that may help persuade people that changes are
needed in handling practice; these are the legal argument,
ethical argument, financial argument, evidence argument and
professional argument (see Box 2).
Conclusion
The history surrounding back pain indicates that it is
now socially acceptable to experience back pain, and in
contemporary society deemed the individual continue
their normal daily routine, with limited justification to rest
and take sick leave from work. The pressures surrounding
job security, increasing workloads and financial strains in
all sectors of the healthcare professions has a spiralling
influence on the individual who experiences back pain.
This study provides an insight into the student nurses’
experience, showing individuals coping with back pain and
self-treating their symptoms. The student nurses’
recommendations are profound and reflect on current
published evidence. Consideration into the worth, value and
dignity of nurses and healthcare professionals deserves
respect, and individual empowerment is paramount to enable
student nurses and nurses not to put themselves at risk when
a safe alternative is evident. Nurses of all levels need to make
decisions to safeguard, promote and protect their own health
and safety, thus not compromising their autonomy as a
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EDUCATION
Figure 1. Student nurses’ causes of back pain during placement.
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Elderly care
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KEY POINTS
n Back pain has been a major cause of health problems for nurses
and midwives.
n In exploring student nurses’ back pain, this study discovers their experience of
back pain and their recommendations of how to reduce back pain incidence
in the workplace.
n This study provides an insight into the student nurses’ experience, showing
individuals coping with back pain and self-treating their symptoms.
n Nurses of all levels need to make decisions to safeguard, promote and
protect their own health and safety.
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