Applied Nursing Research 33 (2017) 72–77

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Applied Nursing Research

journal homepage: www.elsevier.com/locate/apnr

Work related musculoskeletal disorders in primary health care nurses

Tânia Ribeiro, Master a,⁎, Florentino Serranheira, Ph.D. b, Helena Loureiro, Ph.D. c
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

a r t i c l e i n f o a b s t r a c t

Article history: Background: Work related musculoskeletal disorders (WRMSDs) constitute a serious occupational health prob-
Received 23 July 2015 lem among registered nurses (RN) all around the world. Its prevalence is mainly associated with nurses' high
Revised 10 September 2016 physical demands that still remain poorly studied in primary health care (PHC).
Accepted 11 September 2016 Purpose: To describe nurses' self-reported symptoms of WRMSDs (mainly discomfort and pain) in PHC, featuring
Available online xxxx
the main 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
Keywords:
Epidemiology
worked on PHC in Portugal. Nurses answered an online Portuguese version of the Nordic Musculoskeletal Ques-
Nursing tionnaire (NMQ) (surveymonkey platform). Data was analyzed using the Statistical Package for the Social Science
Occupational health (SPSS17) program. Statistical analysis was based on descriptive statistics and associations with the χ2 test,
Primary health care Cramér's V, Mann–Whitney and 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).
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

http://dx.doi.org/10.1016/j.apnr.2016.09.003
0897-1897/© 2016 Elsevier Inc. All rights reserved.
 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 the χ 2 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) indicate the tasks and workplaces that nurses' physical demands allow
Nurse 19.1
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
Between 21 and 34 years 24.9 • a greater propensity of female nurses to have WRMSDs symptoms
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

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
(Martins, 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-
gl p
tervention, not 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
3 0.009
each of these 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.

Wound care frequency

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-
More than 10 times per day 187 1656 1601
tions 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

interference of uncontrolled factors. The high propensity of the sample References

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5. Conclusions
It was found a high number of PHC nurses' WRMSDs symptoms
(89%) that require responsiveness. Self-reported symptoms affect dif-
ferent body regions. Low back symptoms are (63.1%) particularly prev-
alent in this nurses group. This study adds up to a growing body of
evidence and put forward PHC nurses are exposed to diverse risk factors
that cause a high prevalence of WRMSDs symptoms related with the
nurses' working tasks.
Half of the PHC nurses (51.4%) in this study report work related ab-
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Further research should be conducted to establish the epidemiology
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pational prevention and control programs in PHC centers that include
organizational, technical and even individual measures to promote the
active participation of nurses in a process that definitely leads to a
change: WRMSDs prevention.
Conflict of interest
The authors declare that there are no conflicts of interests regarding
the publication of this paper.
Author Contributions
All authors confirmed they have contributed to the intellectual con-
tent of this paper.
Acknowledgements
Authors are grateful to all nurses that participated in this study. The
authors would also like to acknowledge the Portuguese Registered
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