Applied Nursing Research 33 (2017) 72–77

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Applied Nursing Research

journalhomepage:www.elsevier.com/locate/apnr

Work related musculoskeletal disorders in primary health care nurses

a, b c
Tânia Ribeiro, Master , Florentino Serranheira, Ph.D. , Helena Loureiro, Ph.D.
a Community Nurse Specialist, Unidade de Cuidados de Saúde Primários - Penha de França, 1170-201 Lisbon, Portugal
b Ergonomist, Escola Nacional de Saúde Pública, Universidade NOVA de Lisboa; CISP, Avenida Padre Cruz, 1600-560 Lisbon, Portugal
c Professor, Escola Superior de Saúde, Universidade de Aveiro, 3810-193 Aveiro, Portugal

article info abstract

Article history: Background: Work related musculoskeletal disorders (WRMSDs) constitute a serious occupational health prob-lem among
Received 23 July 2015 Revised registered nurses (RN) all around the world. Its prevalence is mainly associated with nurses' high physical demands that still
10 September 2016 Accepted remain poorly studied in primary health care (PHC).
11 September 2016 Available Purpose: To describe nurses' self-reported symptoms of WRMSDs (mainly discomfort and pain) in PHC, featuring the main
online xxxx work tasks that may have risk factors for its development.
Methods: A cross-sectional study was developed to identify self-reported WRMSD symptoms by nurses that worked on PHC
Keywords:
in Portugal. Nurses answered an online Portuguese version of the Nordic Musculoskeletal Ques-tionnaire (NMQ)
Epidemiology
(surveymonkey platform). Data was analyzed using the Statistical Package for the Social Science (SPSS17) program.
Nursing 2
Occupational health Statistical analysis was based on descriptive statistics and associations with the χ test, Cramér's V, Mann–Whitney and
Primary health care Kruskal–Wallis test, with a significance level of 5%.
Work related musculoskeletal disorders symptoms Results: A sample (n = 409), mostly female (84.0%), showed a high prevalence of WRMSDs symptoms in the last 12 months
(89.0%). The lower back was the most affected body region (63.1%), followed by cervical, dorsal, shoulders and the
wrist/hand. In the same period, absenteeism related to these complaints was high (51.4%) and strongly connected with
standing work (48.8%), bending the trunk (42.3%), rotating the trunk (40.6%), ap-plying force with hands or fingers (37.3%),
sitting work (36.6%) and repetitive arm movement (34.3%). This study showed associations between the prevalence of
WRMSDs symptoms in different body regions and some individual characteristics such as: gender, age, BMI, presence of
other pathologies and regular physical exercise. Conclusions: This study indicates that, as in other areas of nursing practice, in
PHC nurses are also exposed to risk factors that are linked with a high prevalence of WRMSDs symptoms. “Inadequate” and
extreme postures sustained for prolonged periods and their repetitiveness will contribute to this occurrence. This shows the
need to develop occupational prevention programs to curb this occupational health issue among PHC nurses.

© 2016 Elsevier Inc. All rights reserved.

1. Introduction
Nurses are the most affected healthcare professionals with regard to their
health, comfort and safety (Faria, 2008). Because of the specificity of their
work tasks and the long duration of tasks in health institutions, they are quite
vulnerable to various occupational risk factors (Bessa, Almeida, Araújo, &
Silva, 2010; Farias & Zeitoune, 2005). Prolonged ex-posure to risk factors
(which include physical, biological, chemical, er-gonomic and psychosocial
factors) may contribute to the occurrence of occupational health disorders and
the development of occupational diseases of diverse etiology, including the
WRMSDs (Aguiar, Barreto, Aguiar, Biazzini, & Silva, 2009; Faria, 2008;
International Council of Nurses [ICN], 2009; Tinubu, Mbada, Oyeyemi, &
Fabunmi, 2010).
WRMSDs are a group of disorders confined to muscles, joints, tendons,
ligaments, nerves and bones, sometimes including the localized blood cir-
culation system, whose origin or aggravation is mainly due to professional
Corresponding author. Tel.: + 351 963831278.
E-mail address: taniaribeiro29@hotmail.com (T. Ribeiro).
http://dx.doi.org/10.1016/j.apnr.2016.09.003
0897-1897/© 2016 Elsevier Inc. All rights reserved.
activity and effects of working conditions in which task performance oc-curs
(European Agency for Safety and Health at Work [EASHW], 2010).
In addition to the physical risk factors connected to the work tasks, there
are also individual risk factors, related to each individual's suscep-tibility and
organizational/psychosocial risk factors (although these oc-cupational risk
factors are often addressed separately), whose control is critical (EASHW,
2010; National Program Against Rheumatic Diseases: Musculoskeletal
Injuries Related to Work, 2008; Nunes, 2006; Malchaire, Cock & Vergracht,
2001; Serranheira, Uva & Lopes, 2008).
WRMSDs statistical data in Portugal is scarce, and for that reason it is not
possible to know accurately its true importance (National Program of
Occupational Health [NPOH] 2009–2012, 2009). Although WRMSDs are
recognized as relevant occupational diseases and notification is mandatory,
the symptoms are undervalued either by the workforce or by the general
population. However, the European Survey on Working Conditions,
conducted in 2005, revealed that 30.7% of Portuguese workers reported back
pain and 28.8% suffered from myalgia (EASHW, 2010). The first
epidemiological study of the active Portuguese popula-tion
regarding the
prevalence of WRMSDs (referred to in this context by
 T. Ribeiro et al. / Applied Nursing Research 33 (2017) 72–77
occupational rheumatic diseases), found that 5.9% of study participants'
employees (24,269 cases) had clinically relevant work-related injuries in 2009
(Cunha-Miranda, Carnide & Lopes, 2010).
Nursing work is one of the most perilous occupations in the healthcare
sector. Results obtained in studies conducted in several countries show that
WRMSDs constitute a serious occupational health problem among nurses
throughout the world (American Nurses Associ-ation [ANA], 2004; Anap,
Iyer & Rao, 2013; Serranheira, Sousa & Uva, 2010; Tinubu et al., 2010;
Trinkoff, Lipscomb, Geiger-Brown, Storr, & Brady, 2003).
These conditions have a strong impact in terms of absenteeism, de-creased
productivity and premature retirement, resulting social-economic costs, either
direct or indirectly (Nunes, 2006). The negative influence of WRMSDs on
nurses' health and quality of life will directly influence their performance, but
also indirectly influence the quality of nursing care provided to patients (Anap
et al., 2013; Cotrim et al., 2006; EASHW, 2010; ICN, 2009; Tinubu et al.,
2010). Epidemiological in-vestigations highlight the high WRMSDs
morbidity rate among nurses. This has been linked to high physical demands
that their work tasks re-quire and the conditions in which they are developed
(Alexopoulos, Burdorf, & Kalokerinou, 2006; Anap et al., 2013; Choobineh,
Rajaeefard, & Neghab, 2006; Coelho, 2009; Fonseca & Serranheira, 2006;
Martins, 2008; Tinubu et al., 2010; Serranheira, Cotrim, Rodrigues, Nunes &
Sousa-Uva, 2012a, 2012b). The physiologically “inadequate” and extreme
postures (outside the intersegmental joint comfort angles) adopted in work
tasks involving the mobilization of patients are considered the main risk
factors in the etiology of WRMSDs in nurses. They include repet-itive
movements such as lifting, transferring and repositioning of patients, often
performed manually (without the use of mechanical devices), and therefore
requiring an increased physical applied force (ANA, 2004; Nelson, 2006;
NIOSH, 1997; Serranheira et al., 2012a, 2012b), sometimes exceeding nurses'
physical capabilities.
The sitting position cans also leading to the development of muscu-
loskeletal symptoms. When adopted for long periods of time (hours) spinal
disc compression is increased, eventually leading to higher loads on the spine.
When spine movement is included in sitting posture (for instance flexion and
rotation of the trunk), together with the ab-sence of work breaks, the physical
load on the spine will exponentially increase (particularly in the lower back),
causing fatigue, pain and a gradual decrease in ability to work (productivity)
(Guedes, 2008; Nunes, 2010).
Repetitiveness in nursing tasks resulting from specific work de-mands,
workplace conditions and equipment, namely the repetition of the same
actions and movements, adopting postures considered “inad-equate” and
extreme and/or force applications with the same anatomi-cal regions, for
extended periods of time, are the main contributors for nurses' WRMSDs
(Serranheira et al., 2008).
In Portugal, previous studies have shown the high prevalence of
WRMSDs symptoms in nurses in recent years and have pinpointed sev-eral
risk factors and working conditions to which they are exposed. The results of
these investigations converge, in general, with strengthening international
results, hence the relevance of WRMSDs problem. Howev-er, research data is
scarce (only some Portuguese studies were found) (Carneiro, Braga, &
Barroso, 2012; Coelho, 2009; Fonseca & Serranheira, 2006; Galego, 2009;
Martins, 2008; Nelson, 2006; Serranheira et al., 2010; Serranheira et al.,
2012a, 2012b) and all data that is currently available refers almost exclusively
to nurses working in a hospital con-text, disregarding other working contexts
such as nursing at PHC.
In fact, only two studies cited above mention PHC nurses (Carneiro et al.,
2012; Galego, 2009). In addition to similar working risk factors to which
nurses are exposed, they also added the large number of com-plex
discontinuous requests they have to fulfill over a working day (Aguiar et al.,
2009; ICN, 2009). Simultaneously, the contact with a greater diversity of
caring contexts demand different levels of knowl-edge and responsibilities;
for instance, developing their tasks at the health center facilities, or at the
users' own homes (home care).
73
A study with a small nurse's sample gives special emphasis to those that
provided home care. This study revealed a high prevalence of mus-
culoskeletal symptoms in these professionals and stated that home care nurses
were three times more likely to develop musculoskeletal com-plaints in the
lower back (Carneiro et al., 2012).
It is noted that in Portugal, in PHC, a nurse can develop their work ac-
tivities in different contexts, as “inside” of the health center, or “out-side”, in
the patients home (home care) or in institutionalized groups in health centers
coverage (like schools). That often happens during the same working day and
gives rise to different work tasks and WRMSDs risk.
The present study aims at describing the RN self-reported WRMSDs
symptoms in PHC, featuring the major components of the work tasks that
may constitute risk factors for its development.
2. Population and methods
All 7508 PHC Portuguese RN on the Portuguese Registered Nurses Board
(PRNB) – Ordem dos Enfermeiros – in 2010 were invited to answer a
WRMSDs nationwide questionnaire through an advert on the PRNB website.
Nurses who accepted the invitation provided their personal e-mail address and
subsequently received an access link to the ques-tionnaire at the
“surveymonkey platform questionnaire” webpage. The link allowed
respondents either one response at a time or phased re-sponses, according to
each nurse's personal decision. A total of 409 nurses participated (n = 409),
representing 5.4% of all PHC nurses reg-istered in PRNB.
The data collection instrument used is an adaptation of the NMQ
(Kuorinka et al., 1987), which is widely used in Portugal and has been
previously tested for reliability and validity (Serranheira et al., 2008).
Essentially, this questionnaire kept the original structure of the NMQ and was
divided into four main sections: (i) socio-demographic charac-teristics, for
instance, gender, age, weight, height and professional category; (ii) self-
reference of WRMSDs symptoms in nine body areas (cervical, dorsal, lower
back, shoulders, elbow, wrist/hand, thighs, knees and ankles/feet); (iii)
identification of nurse's work tasks and their relationship with WRMSDs
symptoms and (iv) health status char-acterization. An observational,
quantitative, descriptive/exploratory and cross-sectional study was developed.
Statistical analysis was based on descriptive statistics and associations with
2
the χ test, Cramér's V and Mann–Whitney and Kruskal–Wallis, with a
significance level of 5% (p ≤ 0.05). The data analyses were carried out using
SPSS 17.0 version software.
3. Results
From 409 PHC nurses respondents, 84.0% were female. The mean age
was 39.5% (±8.8) years, with a minimum age of 23 years and the maximum
of 68 years. Most respondents are in the age range between 31 and 40 years
and between 41 and 50 years (35.7% and 35.9%, respec-tively). The most
frequent occupational category is graduate nurses (45.5%), followed by
specialist nurses (26.4%) and nurses (19.1%). As for the experience years,
most nurses have between 7 and 20 years of profession (56.7%), only 1.5% of
respondents had more than 35 years of nursing (Table 1).
Most of the respondents (89.0%) presented WRMSDs symptoms in one or
more body regions in the last 12 months. The lower back was the most
affected body region (63.1%), followed by the cervical (50.1%) and dorsal
region (40.9%). The smaller prevalence of WRMSDs symptoms was at the
thighs (8.9%) and elbows (7.2%) (Fig. 1).
In the last seven days, the presence of musculoskeletal complaints was
reported by the majority of nurses (63.5%). These complaints oc-curred
predominantly in the lower back (32.8), neck (27.1%), dorsal re-gion (22.0%)
and shoulders (19.8%) (Fig. 1).
Half of the respondents (51.4%) (n = 208) reported having been un-able to
perform their usual tasks (absenteeism) in the last 12 months,
74 T. Ribeiro et al. / Applied Nursing Research 33 (2017) 72–77

Table 1 This study shows a relationship, although not statistically significant,

Distribution of the sample according to variables: “gender”, “age”, “professional category” between the WRMSDs symptoms and some of the nursing work tasks,
and “experience years. namely: ankles/feet complaints and the computerized work (p =
Variable % 0.006) (r = 0.177), administering medication (p = 0.023) (r =
Gender (n = 407) 0.162), symptoms in shoulders (p = 0.043) (r = 0.155) and invasive
Female 84.0 procedures.
Male 16.0 The most frequent components of the work tasks mentioned by
Age (n = 409) nurses as being strongly related with the development of WRMSDs
≤30 years 17.1
31 and 40 years 35.7 symptoms were: standing work (48.8%), bending the trunk (42.3%), ro-
41 and 50 years 35.9 tating the trunk (40.6%), applying force with hands or fingers (37.3%),
≥51 years 11.3 sitting work (36.6%) and repetitive arm motion (34.3%). These results
Professional category (n = 409) 19.1 indicate the tasks and workplaces that nurses' physical demands allow
Nurse them to identify the main risk factors for WRMSDs among PHC nurses.
Graduate nurse 45.5
Specialist nurse 26.4 Results also showed associations between the prevalence of
Head nurse 8.3 WRMSDs symptoms in different body regions and individual character-
Supervisor nurse 0.7 istics, such as: gender, age, body mass index, presence of pathologies
Experience years (n = 402) and regular physical exercise:
Under 6 years 16.9
Between 7 and 20 years 56.7 • a greater propensity of female nurses to have WRMSDs symptoms
Between 21 and 34 years 24.9
More than 35 years 1.5 in shoulders (r = 0,105; p = 0,036) and ankles/feet (r = 0,170;
• p = 0,001), compared with male nurses;
the prevalence of musculoskeletal complaints in shoulders (p =
because they felt discomfort, pain, fatigue and/or edema (WRMSDs 0,032) in nurses aged 41 to 51 years and in the elbows (p =
symptoms) in one body region at least. These complaints were located 0,040) and dorsal region (p = 0,040) at younger ages (between
predominantly in the dorsal region (35.9%), followed by the lower 31 and 40 years);
back (10.8%), neck (7.3%) and shoulders (Fig. 1). • a relationship between WRMSDs symptoms at knees (p = 0,011) and
The tasks that nurses performed more frequently during the working body mass index. Nurses being overweight self-reported more mus-
day (more than 10 times/day) were computerized work (69.6%), wound culoskeletal complaints in knees than nurses of standard-weight;
care (51.5%), evaluation of blood pressure/glucose and others (42.5%), ad- • higher propensity to suffer of any pathology, such as nurses with more
ministering medication (29.7%) and home care (11.9%) (Table 2). advanced age (p = 0,0026), body mass index (p = 0,014) and weight
Additionally, using the Kruskal–Wallis test, statistically significant (p = 0,039) and greater time in the profession (p = 0,014);
differences have been identified between the number of body regions • a greater number of breaks during the working day and lower ab-
affected by WRMSDs symptoms in the past seven days, the frequency senteeism (r = −0,167; p = 0,021) in nurses who practice physical
of administering medication (χ2(3) = 11.545; p = 0.009) and wound exercise.
care frequency (χ2(3) = 15.563; p = 0.001). These differences progress
toward a greater frequency of work tasks, leading to an increased num- These results suggest the need to understand individual risk factor
ber of affected body regions (Table 3). contributions in the study of the WRMSDs problem among PHC nurses.

Fig. 1. WRMSDs symptom prevalence (last 12 months and 7 days) and absenteeism (last 12 months).
 T. Ribeiro et al. / Applied Nursing Research 33 (2017) 72–77 75
Table 2

Frequent nursing tasks during a working day.

Frequency
Nursing Tasks 0–1 times per 2 and 5 times per 6 and 10 times More than 10
day day per day times per day
n.° % n.° % n.° % n.° %
Computerized work 16 4.1 51 12.9 53 13.4 275 69.6
Invasive procedures (intubation, indwelling catheters, punctures) 208 61.5 101 29.9 20 5.9 9 2.7
Wound care 36 9.9 56 15.3 85 23.3 188 51.5
Administering medication 64 17.8 111 30.8 78 21.7 107 29.7
Evaluation of blood pressure/glucose and others 40 9.8 68 18.4 104 28.2 157 42.5
Home care 101 33.3 103 34.0 63 20.8 36 11.9
Hygiene and comfort in bed 117 84.2 18 12.9 2 1.4 2 1.4
Positioning/moving patients in bed 112 48.3 79 34.1 28 12.1 13 5.6
Transfer or transportation of patients 108 62.8 48 27.9 11 6.4 5 2.9
Patient bed lifting without mechanical assistance 120 65.6 45 24.6 13 7.1 5 2.7
Patient bed lifting with mechanical assistance 97 92.4 6 5.7 1 1.0 1 1.0
Patient feeding 96 89.7 7 6.5 2 1.9 2 1.9
Hygiene and comfort in the bathroom 91 91.0 7 7.0 1 1.0 1 1.0

4. Discussion often turn to self-medication as a treatment for WRMSDs symptoms (Martins,

Results denote a high WRMSDs symptoms prevalence in Portuguese PHC
nurses, in last 12 months (89.0%). They were quite similar to other na-tional
and international studies carried out in PHC (Carneiro et al., 2012; Cheung,
Gillen, Faucett, & Krause, 2006; Coelho, 2009) or other work con-texts
(Alexopoulos et al., 2006; Choobineh et al., 2006; Engels, van der Gulden,
Senden, & van't Hof, 1996; Gurgueira, Alexandre, & Filho, 2003; Josephson,
Lagerström, Hagberg, & Wigaeus Hjelm, 1997; Knibbe & Friele, 1996;
Magnago, Lisboa, & Griep, 2008; Martins, 2008; Tinubu et al., 2010; Simon
et al., 2008). However, some differences in work context may be re-lated with
the WRMSDs symptoms prevalence (Table 4).
This study also emphasizes the high prevalence of WRMSDs nurses'
symptoms at the lower back area (63.1%). That agrees with what was
generally and empirically evidenced through different studies in the range of
all WRMSDs that affect nurses: disorders at the lower back are the most
common, although other body regions are also affected.
WRMSDs symptoms may influence the high absenteeism level in PHC
nurses (51.4%). This is similar to a study conducted by Martins (2008), about
the perception of risk of musculoskeletal injuries in nurs-ing task
performance. This author reported that occupational accidents associated with
WRMSDs were the main contributors to the loss of working days (on average
25.8 days), and the second most frequent type of occupational accidents in
nurses (27.2% of references). Accord-ing to United States Bureau of Labor
Statistics (2011), in 2010, the inci-dence rate of WRMSDs in the USA
increased 10.0% compared to 2009 and caused 53.030 days of absence from
work.
Conversely, Fonseca and Serranheira (2006) and Carneiro et al. (2012)
demonstrated in their research that the majority of nurses were not prevented
from doing their normal work, whilst stating a high prevalence of
musculoskeletal disorders complaints.
For some authors the value of absenteeism level is not greater be-cause
nurses (mainly due to their own education and self-knowledge)
Table 3
Number of body regions affected in the past 7 days by frequency of daily tasks.
f σ χ2
X
Administering medication frequency
0–1 times per day 64 0.967 1235 11.545
2–5 times per day 108 1569 1493
6–10 times per day 78 1234 1429
More than 10 times per day 107 1702 1745
Wound care frequency
2008). At the same time, the fact that WRMSDs appear insid-iously or reveal
late effects may hinder or prevent nurses to establish a cause/effect
relationship between musculoskeletal symptoms and their work tasks and thus
limit the adoption of occupational strategies for prevention. These facts
undervalue the problem and its real scope is un-known among nurses and may
contribute to premature retirement.
Nurses' PHC daily physical demands, such as reported in this study,
computerized work, wound care, evaluation of blood pressure/ glucose/others
and administering medication, often require them to re-peatedly change their
body position from the anatomical best/correct posture to provide a
successfully task. In fact, typical “inadequate” pos-ture examples involve
situations where the work object is above the worker's head or closer to the
ground, forcing him/her to stand with hands above the head or, conversely, to
work bent over or crouched down (Simoneau, St-Vincent & Chicoine, 2013).
Results confirm that “inadequate” and extreme postures causing a de-
viation of postural alignment, that are maintained and repeated daily for
prolonged periods, such as bending/rotating the trunk and standing work (self-
reported by PHC nurses as being strongly related with WRMSDs symptoms),
increased the risk of WRMSDs symptoms (Nelson, 2006; Martins, 2008;
Moreira & Mendes, 2005) and shows the need to review nurses' working
conditions.
It is known that each body position calls for different muscles and shifting
the way certain muscles are stimulated provides relief for others, it is evident
that there is a need for information aimed at nurses regarding adopting
comfortable working positions that allow the distri-bution of effort by the
various body segments in order to minimize physical fatigue. Further research
should be conducted, based on tech-niques and procedures used in
ergonomics, in order to allow a detailed study of the type, frequency and
duration of body postures for different the work tasks of PHC nurses.
This study also evidences associations between nurses' individual
characteristics and WRMSDs symptoms in different body regions which
recall the importance of including a review of individual variables in the risk
assessment process to allow for successful prevention and in-tervention, not
gl p
limited to aspects related with their own working condi-tions and tasks. In
fact, individual risk factors are specific characteristics that vary from
individual to individual; the role and contribution that each of these
3 0.009
characteristics has on the origin and/or WRMSDs develop-ment causes some
controversy in ergonomics and epidemiological liter-ature that should be
analyzed in this context.

0–1 times per day 36 0.722 1186 15.563 3 0.001 4.1. Limitations
2–5 times per day 55 1455 1372
6–10 times per day 84 1298 1581
The generalization of the above results should consider the limita-tions
More than 10 times per day 187 1656 1601
attributed to the cross-sectional studies, as they allow the
76 T. Ribeiro et al. / Applied Nursing Research 33 (2017) 72–77

Table 4
WRMSDs symptoms prevalence in last 12 months: comparison of results from different national and international studies.

Study WRMSDs symptoms prevalence (%)

Anatomical body regions
Work context Lower back Dorsal region Cervical region Shoulders Wrist/hand
Engels et al. (1996) Nursing homes for the elderly 33.8 7.9 22.9 19.5 5.7
Josephson et al. (1997) Hospital 64.0 30.0 53.0 60.0 –
Gurgueira et al. (2003) Hospital 5.0 21.9 28.6 40.0 24.8
Trinkoff et al. (2003) Hospital 32.0 – 24.0 22.0 –
Smith et al. (2004) Hospital 56.7 38.9 42.8 40.0 –
Fonseca and Serranheira (2006) Hospital 65.0 37.0 55.0 34.0 30.0
Cheung et al. (2006) PHC 55.9 51.2 62.9 73.1 30.3
Choobineh et al. (2006) Hospital 54.9 46.4 36.4 39.8 39.3
Martins (2008) Hospital 72.7 32.2 – – –
Tinubu et al. (2010) Hospital 44.1 16.8 28.0 12.6 16.2
Carneiro et al. (2012) PHC 64.6 49.0 73.5 49.0 31.3
Serranheira et al. (2012a, 2012b) Hospital/PHC and others 60.2 44.5 48.6 35.6 28.1
Anap et al. (2013) Hospital 48.2 – 33.1 34.6 –
This study (2013) PHC 63.1 40.9 50.1 37.8 28.4

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Conflict of interest
The authors declare that there are no conflicts of interests regarding the
publication of this paper.
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All authors confirmed they have contributed to the intellectual con-tent of
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