I S S U ES A F FE C T I N G W O R K F O R C E W E L L BE I N G

The incidence of low back problems among nursing students in

Hong Kong
Kin Cheung

Aims. To determine the cumulative incidence (CI) of and risk factors for musculoskeletal problems among nursing students in
Hong Kong.
Background. Although low back problems have been identified internationally as one of the major work-related hazards among
nursing personnel, only a few studies have examined the problem among nursing students.
Design. Two-year prospective cohort study; data collected at baseline and 2 (T1), 12 (T2) and 26 (T3) months after baseline.
Methods. Three cohorts [i.e. two full-time (FT) and one part-time (PT) cohorts] of nursing students were recruited from one of
the universities in Hong Kong. They were invited to complete a baseline and three follow-up questionnaires. CIs of low back
problems among the three cohorts were calculated and tested for their association. The multivariate logistic regression was also
used to identify the risk factors for low back problems.
Results. Initially, the seven-day, 30-day and 12-month prevalence in baseline as well as the T1 (64%) and T2 (94%) CIs of low
back problems for the PT cohort were significantly higher than those of the two FT cohorts (their CIs ranged from 45–67%).
However, the CIs for the FT cohorts were increased from 45% at T1–83% at T3, while the CIs for the PT cohort was only
increased from 64–80%, respectively. At T3, the CIs for both FT cohorts caught up with the CI for the PT cohort (v2 = 0Æ068,
p = 0Æ07). As expected, the risk factors for low back problems were multifactorial, i.e. personal, psychosocial and physical.
Conclusion. Nursing students had similar CI of low back problems as registered nurses 26 months after baseline, i.e. during
their nursing training and before becoming a registered nurse.
Relevance to clinical practice. The results of this study, for the first time, identified that low back problems were developed
during the period of nursing school training rather than after nurses enter the workforce. These findings have crucial impli-
cations for reducing low back problems among nursing personnel. There is a need to evaluate nursing students’ experience in
their nursing study and provide appropriate support to them to reduce their personal, physical and psychosocial stress. The
ability of nursing students to deliver high quality patient care depends in part on their ability to conserve their own health and
well-being.

Key words: cumulative incidence, nurses, nursing students, prospective cohort study, risk factors

Accepted for publication: 30 June 2009

has been found that nursing personnel have a much higher

Introduction
Low back problems have been identified internationally as
one of the major work-related hazards facing nursing
personnel (Maul et al. 2003, Charney & Hudson 2004). It
incidence and prevalence rate of back problems than other
occupations, such as fork-lift-truck driver, construction
labourers and teachers (Jensen 1987). The annual prevalence
of work-related back pain among nursing personnel ranged

Author: Kin Cheung, PhD, RN, Assistant Professor, School of Nursing, The Hong Kong Polytechnic University, Hung Hom,
Nursing, The Hong Kong Polytechnic University, Hong Kong, China Kowloon, Hong Kong, China. Telephone: (852) 2766-6773.
Correspondence: Kin Cheung, Assistant Professor, School of E-mail: hskin@inet.polyu.edu.hk

Ó 2010 The Author. Journal compilation Ó 2010 Blackwell Publishing Ltd, Journal of Clinical Nursing, 19, 2355–2362 2355
doi: 10.1111/j.1365-2702.2009.03091.x
K Cheung
from 36Æ9–75Æ0% (Menzel 2004). Morgan and Chow (2007)
found that the average cost for replacing a registered nurse
turnover and time loss because of back problems was from
US$25 450–38 280. The high prevalence and high costs
associated with work-related back problems in nursing have
attracted the attention of many researchers (Menzel et al.
2006, Dawson et al. 2007, Jang et al. 2007).
However, despite many studies examining back problems,
the occurrence of work-related back problems among nursing
personnel remains high (Feyer et al. 2000). The literature
indicates that numerous investigations have been conducted
among practising qualified registered nurses; however, only a
few studies have examined the problem among nursing
students (Klaber Moffett et al. 1993, Feyer et al. 2000, Smith
et al. 2003, Smith & Leggat 2004). Smith and Leggat (2004)
found that nursing students had a higher prevalence of low
back pain than registered nurses; this finding indicates the
need to shift the focus of research from registered nurses to
nursing students. The belief that registered nurses acquire
musculoskeletal problems from their work has been ques-
tioned. However, if such problems begin during the nursing
training period, there will be implications for nursing
curricula and for the support nursing students receive.
Hence, a two-year prospective cohort study has been
conducted to determine the cumulative incidence (CI) of and
risk factors for musculoskeletal problems among nursing
students. The specific aim is to compare the differences
among three cohorts [i.e. full-time Higher Diploma in nursing
(FT HD), full-time Bachelor of Science in Nursing (FT BSN)
and part-time Bachelor of Science in Nursing (PT BSN)] for
their CI of and risk factors for low back problems.
Subjects and methods
Three cohorts of nursing students were recruited from one of
the universities in Hong Kong. The students were admitted
for the academic year of 2002–2003, and the cohorts were
from the FT HD, FT BSN and PT BSN. The two FT cohorts
were recent high school graduates and therefore had no
previous nursing experience. However, the PT cohort
included frontline registered nurses who had graduated with
a HD, and they were continuing their BSN study on a PT
basis. It takes three years, four years and two years to
complete the FT HD, FT BSN and PT BSN, respectively. All
of the students (i.e. 158 FT HD, 110 FT BSN and 120 PT
BSN students) were invited to participate in the study.
Explanations of the purpose and procedures of the study were
provided in the classroom setting. Baseline data were
collected during the first two weeks after school commen-
ced in September 2002. An information sheet and the
2356 Ó 2010 The Author. Journal compilation Ó 2010 Blackwell Publishing Ltd, Journal of Clinical Nursing, 19, 2355–2362
questionnaire were distributed in the classroom. Ethical
clearance was obtained from the University.
Based on the literature review, the investigators developed
a baseline questionnaire named ‘Study on Nursing Students’
Musculoskeletal Problems Questionnaire’. The questionnaire
comprises three sections. Section I involves demographical
items such as age, gender, height, weight, smoking history,
exercise pattern and computer usage. Section II contains
items related to musculoskeletal problems. Nursing students
were asked to indicate whether they had had problems such
as aches, pains, discomfort or numbness, which had lasted
for at least one day in a different part of body during the
last seven days, 30 days and 12 months. The Nordic
Musculoskeletal Questionnaire (NMQ) (Kuorinka et al.
1987) was modified to measure those musculoskeletal
problems which are the dependent variables of the study.
The NMQ is the most widely used symptom survey tool in
occupational health worldwide, especially in European
countries (Baron et al. 1996), such as Denmark, Finland,
Norway and Sweden (Kuorinka et al. 1987). The NMQ has
been used in more than 100 different projects as well as
for routine use in occupational health services. In addition,
one or more questions in the NMQ have been administered
to over 50,000 persons (Kuorinka et al. 1987). The validity
and reliability of the NMQ have been reported by the
original Nordic committee (Kuorinka et al. 1987). Section
III involves questions on psychosocial stress, which include
the frequency (never, occasionally and frequently) of the
following symptoms: headache, constant tiredness, low
mood, feeling tense, under stress, fatigue and anxiety
(Smedley et al. 1997). The 17 psychological stress response
variables developed by Karasek (1985) were also used.
Nursing students were asked to indicate the frequency
(never, rarely, sometimes and often) that they felt depressed,
fearful, lonely, happy and 13 other psychological stress
response variables.
The follow-up questionnaires (i.e. T1, T2 and T3) were
almost identical to the baseline questionnaire except for some
physical activities (such as the frequency of sitting, standing,
walking, computer use, head bending forward, lifting or
carrying objects and climbing stairs) which were included in
all follow-up questionnaires. The average physical activities
score was used for analysis.
Both the baseline and follow-up ‘Study on Nursing
Students’ Musculoskeletal Problems Questionnaires’ were
tested for face and content validity. A panel of four local and
overseas experts in the musculoskeletal field was invited to
verify the validity of the questionnaire. Validity was calcu-
lated by a content validity index (CVI) (Lynn 1986), and the
CVI for the entire questionnaire was 1, while the overall CVI
Issues affecting workforce wellbeing The incidence of low back problems

for items was about 0Æ99. Two-week test–retest reliability
was 0Æ70.
Statistical analysis
The data analysis was conducted using the statistical package
for the social science (SPSS ) version 10 (SPSS Inc., Chicago, IL,
USA). Descriptive statistics such as frequencies, means,
standard deviation and percentages were used to describe
the independent and dependent variables (i.e. CI of low back
problems). Calculation of CI was based on the ratio of
number of new cases of low back pain during a period to
population exposed during this period. Hence, nursing
students who had low back problems in the last 30 days at
baseline were excluded from the CI calculation. Chi-square
was used to test the association among three cohorts in terms
of their prevalence and CIs. The multivariate logistic regres-
sion model was used to relate each independent variable with
a binary indicator (Yes or No) for low back problems
adjusted for age, gender and height. The exponentiation of
the coefficients of this model can be used to estimate odds
ratios for each of the independent variables. The statistical
significance of the tests was assessed at p < 0Æ05.
Results
At baseline, 388 questionnaires (i.e. 158 FT HD, 110 FT BSN
and 120 PT BSN students) were distributed, and the response
rate was 100% for HD FT, 97% for BSN FT and 75% for PT
BSN. Table 1 summarises the response rate among three
cohorts in different time intervals. The response rate ranged
from 40–100%. Overall, the response rates for FT cohorts
were higher than the PT cohort. The percentages of students
that withdrew from the programmes were 5% (n = 8) for HD
FT, 2% (n = 2) for BSN FT and 7% (n = 6) for BSN PT
cohorts.
Characteristics of study participants at baseline are given in
Table 2. Although the BSN PT cohort was slightly older than
the FT cohorts, they were all young adults. More than 70%
of the participants were women. None of participants in the
FT cohorts were married, and only 11% (n = 10) of the PT
cohort were married. Close to 100% of participants were
non-smokers. About two-thirds of them occasionally per-
formed exercise at a moderate intensity for 20 minutes three
times a week or more. All the participants had normal body
mass index (BMI). Based on Berman et al. (2008), BMI
ranged from 18Æ5–24Æ9, which is normal.
At baseline, 7-day, 30-day and 12-month prevalence of low
back problems were measured among three cohorts. At T1,
T2 and T3, two-month, 12-month and 26-month CIs of low
back problems were calculated, respectively (See Table 3).
The two-month, 12-month and 26-month CIs for overall FT
cohorts were 45, 67 and 83%, respectively. Chi-square
analyses indicated that there were no differences between
the two FT cohorts in terms of their prevalence and CI.
However, the three points of prevalence for the PT cohort
were significantly higher than those of the two FT cohorts
(p < 0Æ001). It is interesting to observe that the CIs for the
FT cohorts were increased from 45–83%, while the CI for the
PT cohort was increased from 64–94%. In addition,

Table 1 Number of questionnaires

No. of returned follow-up questionnaires
returned among three cohorts at different Time intervals in month after
time intervals baseline (month year) 0 T1 T2 T3 Response rate (%) (n)

HD FT
Baseline (September 2002) 158 100 (158)
2 (November 2002) 153 97 (158)
12 (September 2003) 135 90 (150)
26 (November 2004) 112 75 (149)
BSN FT
Baseline (September 2002) 107 97 (110)
2 (November 2002) 64 58 (110)
12 (September 2003) 76 70 (108)
26 (November 2004) 100 93 (108)
BSN PT
Baseline (September 2002) 90 75 (120)
2 (November 2002) 90 75 (120)
12 (September 2003) 45 40 (113)
26 (November 2004) 47 42 (113)

0, baseline in September 2002; T1, two months after baseline in November 2002; T2, 12 months
after baseline in September 2003; T3, 26 months after baseline in November 2004.

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K Cheung

Table 2 Characteristics of participants

Cohorts
among three cohorts at baseline
Characteristics HD FT n (%) BSN FT n (%) BSN PT n (%)

Gender
Male 35 (22Æ2) 27 (25Æ2) 15 (16Æ7)
Female 123 (77Æ8) 80 (74Æ8) 75 (83Æ3)
Exercise
Never 16 (10Æ1) 6 (5Æ8) 9 (10)
Occasionally 107 (67Æ7) 70 (67Æ3) 58 (64Æ4)
Often 23 (14Æ6) 19 (18Æ3) 20 (22Æ2)
Always 12 (7Æ6) 9 (8Æ7) 3 (3Æ3)
Non-smoker 155 (98Æ1) 105 (98Æ1) 89 (100)

Mean ± SD Mean ± SD Mean ± SD

Age (year) 19Æ5 ± 0Æ99 19Æ4 ± 1Æ12 25Æ1 ± 3Æ66

Computer use (hours) 2Æ8 ± 1Æ95 2Æ6 ± 1Æ68 2Æ7 ± 2Æ56
Height (cm) 162Æ9 ± 7Æ55 162Æ6 ± 7Æ17 161Æ4 ± 7Æ13
Weight (kg) 51Æ0 ± 8Æ54 52Æ6 ± 8Æ55 53Æ1 ± 10Æ38
Body mass index (kg/m2) 19Æ2 ± 2Æ41 19Æ8 ± 2Æ81 20Æ4 ± 3Æ16

HD, Higher Diploma in nursing; FT, full-time; BSN, Bachelor of Science in Nursing; PT, part-
time.

26 months after baseline, the CIs for both the FT cohorts
caught up with the CI for the PT cohort (v2 = 0Æ068,
p = 0Æ07).
Multivariate logistic regressions were used to determine the
risk factors for low back problems among FT cohorts. This
analysis was not performed for the PT cohort because of
small sample size. With the adjustment of age, gender and
height, the results of the analysis showed that risk factors for
low back problems among FT cohorts were multifactorial,
such as personal (i.e. past history of low back problems,
headache and period pain), physical (i.e. physical activities
such as static loads, sitting, standing, walking, computer use,
head bending forward, lifting or carrying objects and
climbing stairs) and psychological (i.e. low mood, feeling
tense, under stress, fatigue, anxiety and constant tiredness)
(Table 4).

Table 3 Prevalence and cumulative incidence (CI) of low back problems among three cohorts at different time intervals

Prevalence CI

No. of months from baseline 7-day 30-day 12-month T1 T2 T3

HD
0 (September 2002) 14% (22/158) 18% (28/158) 20% (32/158)
2 (November 2002) 48% (60/125)
12 (September 2003) 62% (66/107)
26 (November 2004) 86Æ5% (77/89)
BSN (FT)
0 (September 2002) 11% (12/107) 12% (13/107) 18% (19/107)
2 (November 2002) 38% (19/50)
12 (September 2003) 75% (46/61)
26 (November 2004) 79Æ7% (63/79)
BSN (PT)
0 (September 2002) 64% (58/90) 64% (58/90) 62% (56/90)
2 (November 2002) 64% (14/22)
12 (September 2003) 94% (16/17)
26 (November 2004) 80% (8/10)

Nursing students [i.e. n = 28 for HD; n = 13 for BSN(FT) and n = 58 for BSN(PT)] who had low back problems in the last 30 days at baseline
were excluded from the CI calculation. T1, two months after baseline in November 2002; T2, 12 months after baseline in September 2003; T3,
26 months after baseline in November 2004; HD, Higher Diploma in nursing; FT, full-time; BSN, Bachelor of Science in Nursing; PT, part-time.

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Issues affecting workforce wellbeing The incidence of low back problems

Table 4 Risk of low back problems among full-time study cohorts at different time intervals of follow-up. All risk estimates are adjusted for age,
gender and height

Variables Odds ratio 95% Confidence interval SE Wald p-value

HD – T1
History of low back problems
7 days 5Æ38 1Æ47–19Æ68 0Æ66 6Æ48 0Æ01
30 days 3Æ06 1Æ11–8Æ39 0Æ52 4Æ71 0Æ03
12 months 3Æ2 1Æ25–8Æ25 0Æ48 1Æ17 0Æ02
HD – T2
Headache 4Æ52 1Æ78–11Æ51 0Æ48 10Æ01 0Æ002
Low mood 3Æ12 1Æ31–7Æ41 0Æ44 6Æ63 0Æ01
Feeling tense 3Æ97 1Æ65–9Æ55 0Æ45 9Æ46 0Æ002
Under stress 4Æ52 1Æ76–11Æ62 0Æ48 9Æ78 0Æ002
Period pain 3Æ05 1Æ11–8Æ39 0Æ53 4Æ65 0Æ03
Fatigue 4Æ10 1Æ55–10Æ85 0Æ50 8Æ90 0Æ004
Anxiety 4Æ61 1Æ92–11Æ08 0Æ45 11Æ64 0Æ001
Physical activities (average score) 2Æ59 1Æ06–6Æ35 0Æ46 4Æ33 0Æ04
HD – T3
Constant tiredness 5Æ09 1Æ06–24Æ43 0Æ80 4Æ13 0Æ04
Period pain 5Æ61 1Æ11–28Æ45 0Æ83 4Æ33 0Æ04
BSN – T1
Static loads 2Æ03 1Æ06–3Æ88 0Æ33 4Æ63 0Æ03
BSN T3
Period pain 5Æ56 1Æ46–21Æ14 0Æ68 6Æ34 0Æ01
Could not get going 5Æ07 1Æ45–17Æ70 0Æ64 6Æ47 0Æ01

T1, two months after baseline in November 2002; T2, 12 months after baseline in September 2003; T3, 26 months after baseline in November
2004; HD, Higher Diploma in Nursing; BSN, Bachelor of Science in Nursing.

the back problems of nursing personnel have focused on

Discussion
The present study has, for the first time, identified the CI of
low back problems among nursing students. The strength of
studying incidence is in identifying the number of new cases
that have been developed during the school training period.
Previous studies (Klaber Moffett et al. 1993, Smith et al.
2003, Smith & Leggat 2004) mainly investigated the prev-
alence of low back problems. One of those prevalence studies
conducted by Smith and Leggat (2004) even found that rural
Australian nursing students had a higher prevalence of low
back pain (59Æ2%) than some of the studies on registered
nurses. Menzel (2004) reported that work-related back pain
among nursing personnel has a 12-month prevalence of 36Æ9–
75%. The results of the present study indicated that the
incidence of low back problems among FT cohorts increased
dramatically during the training period and levelled off with
the PT cohort 26 months after the study. The major
contribution of this study is that the high incidence of low
back problems in nursing started from the school training
period rather than from employment as a professional
registered nurse. Researchers have invested tremendous
energy and resources to investigate the low back problems
of registered nurses. In the last few decades, investigations on
work activities and lately on psychosocial factors in the
workplace (Smith et al. 2004, Simon et al. 2008). The results
of this present study might suggest an explanation for the
consistently high prevalence of low back problems among
nursing personnel, which could stem from low back problems
already acquired during their training. Professional nursing
activities such as patient handling and work stress could
aggravate low back problems. Because a history of low back
problems has been consistently identified as a risk factor,
preventive measures should be taken from the start of nursing
school training, rather than in the workplace to proactively
prevent the first occurrence of low back problems.
Standard practice for nursing curricula, worldwide,
demands that nursing students must complete a certain
number of clinical hours in hospitals and other clinical
settings before graduation. In Hong Kong, nursing students
are required to complete at least 1400 clinical hours (The
Nursing Council of Hong Kong 2004). The number of
required clinical hours varies by country. In those clinical
practice hours, nursing students are requested to perform
professional registered nurses’ duties such as manual
handling of patients under supervision. Studies have found
that manual handling of patients is the main physical risk

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K Cheung
factor for back problems (Stobbe et al. 1988, Smith et al.
2005, Rockefeller 2008). Nursing students might lack clinical
experience in manual handling even though they have been
taught manual handling techniques in laboratory settings.
Some studies indicated that a lack of work experience (i.e. the
first three years of employment) is associated with increased
risk of work-related back problems (Garrett et al. 1992,
Cohen-Mansfield et al. 1996, Cheung et al. 2006). Different
strategies such as the use of mechanical lifts and implemen-
tation of a zero lift policy (Collins et al. 2004) have been
studied to determine their effectiveness in reducing work-
related back problems. In addition, various countries such as
Australia, UK and USA have national healthcare policy to
eliminate manual patient lifting and insist on the mandatory
use of mechanical patient lift equipment such as electrically
operated overhead ceiling lifts (Edlich et al. 2005, Hudson
2005). However, no legislation requires healthcare institu-
tions to implement ‘no manual lifting’ in Hong Kong. It is
common to observe nursing students as well as registered
nurses to perform manual lifting of patients in the clinical
settings. Moreover, manual handling techniques are taught in
nursing curriculum. In Hong Kong, nurses should lobby the
‘no manual lifting’ policy. Besides lobbying, healthcare
institutions should be encouraged to use mechanical lifting
devices.
The strength of this study is its prospective cohort study
design, which can determine the temporal relationship
between risk factors and low back problems. The results of
this study support that low back problems are multifactorial
which include personal, physical and psychosocial factors.
These findings were consistent with other studies (Smedley
et al. 1997, Cheung et al. 2006). Most of the risk factors
identified in this study are psychosocial. Those psychosocial
risk factors included under stress, anxiety, feeling tense and
low mood. Results of one Australian study (Lo 2002) showed
that nursing students faced four main stressors. They were
nursing studies, finance, family and health. Stressors in
nursing studies might include having to undertake too many
reading and written assignments, a heavy workload and
receiving no vacation break (Weitzel 2008). Nursing students
in Hong Kong may face similar stressors, some of their
placements are arranged in Christmas break and summer
vacation. Hence, the fatigue and constant tiredness of the
nursing students could be the result of a heavy clinical
workload and alongside finance, family and health stressors.
Nursing students’ physical and psychosocial well-being may
affect the care delivered to patients. However, little is known
about these students’ experiences in their nursing study, and
the literature does not address issues such as the students’
perceptions of day-to-day activities and nursing curriculum.
2360 Ó 2010 The Author. Journal compilation Ó 2010 Blackwell Publishing Ltd, Journal of Clinical Nursing, 19, 2355–2362
There is a need to evaluate what impacts on nursing students’
stress levels and also introduce strategies to reduce their stress
levels.
Although the response rate for BSN PT cohort was
relatively lower than FT cohorts, its response rate of 40–
75% (See Table 1) for a survey study might be acceptable.
Because the 30-day prevalence (64%, n = 58) measured at
baseline for BSN PT cohort was high, and those nursing
students would be excluded from CI calculation, and the
maximum number of BSN PT nursing students available for
CI calculation would be 62. With the response rate of 40%
in T2 (Table 1), the number of BSN PT nursing students
available for the actual CI calculation was reduced to 17
(Table 3). Hence, the limited number of BSN PT nursing
students available for CI calculation was a weakness of this
study. In addition, nursing students might have different
reasons for not returning their questionnaires or to drop out of
the study. Nursing students who returned the questionnaire
might be those who have low back problems. This would
increase the possibility of response bias. To increase the
number of BSN PT nursing students, further research should
be conducted with nursing students in other universities or
institutions in Hong Kong. International collaboration should
be encouraged, because each country may have different
student characteristics, programme curricular requirements,
clinical hours, lifestyles and cultures. For instance, more than
90% of nursing students were non-smokers in the present
Hong Kong study and in Japan (Smith et al. 2003), but one-
fourth of nursing students were smokers in Australia (Feyer
et al. 2000, Smith & Leggat 2004). Moreover, the age of
nursing students in Australia (23–25 years old) was older than
in Japan (20 years old) and Hong Kong (19Æ5 years old). Such
international collaborative studies could identify some com-
mon and unique risk factors, which would help to reduce low
back problems among nursing personnel.
Conclusions
For a few decades, research on low back problems among
nursing personnel has focused on workplace factors. The
results of the present study discovered that low back
problems develop during the period of nursing school
training rather than after nurses enter the workforce. These
findings have crucial implications for reducing low back
problems among nursing personnel, i.e. research should be
undertaken beyond the workplace and extended to the school
training period. There is also a need to evaluate nursing
students’ experience in their nursing study and provide
appropriate support to them to reduce their personal,
physical and psychosocial stress. The ability of nursing
Issues affecting workforce wellbeing
students to deliver high quality of patient care depends in part
on their ability to conserve their own health and well-being.
Relevance to clinical practice
The results of this study, for the first time, identified that low
back problems were developed during the period of nursing
school training rather than after nurses enter the workforce.
These findings have crucial implications for reducing low
back problems among nursing personnel. There is a need to
evaluate nursing students’ experience in their nursing study
and provide appropriate support to them to reduce their
personal, physical and psychosocial stress. The ability of
nursing students to deliver high quality patient care depends
in part on their ability to conserve their own health and well-
being.
Acknowledgement
Funding for this study was provided by The Hong Kong
Polytechnic University.
Contributions
Study design: KC; data collection and analysis: KC and
manuscript preparation: KC.
Conflicts of interest
I have no conflict of interest in this manuscript.
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