International Journal of Nursing Studies 82 (2018) 58–67

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International Journal of Nursing Studies

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

Interventions to prevent and reduce the impact of musculoskeletal injuries T

among nurses: A systematic review
⁎
Amy Richardson, Bronwen McNoe, Sarah Derrett, Helen Harcombe
Injury Prevention Research Unit, Department of Preventive and Social Medicine, Dunedin School of Medicine, University of Otago, PO Box 56, Dunedin 9054, New Zealand

A R T I C LE I N FO A B S T R A C T

Keywords: Background: Musculoskeletal injuries and musculoskeletal pain are prevalent among nurses compared to many
Back other occupational groups.
Nurses Objective: To identify interventions that may be effective at reducing the prevalence and impact of muscu-
Nursing interventions loskeletal injuries and pain in registered nurses.
Occupational-related injuries
Design: Systematic review.
Pain
Systematic review
Data sources: Seven databases were systematically searched, including MEDLINE, CINAHL, EMBASE, PsycInfo,
Academic Search Complete, Health Source Nursing, and the Cochrane Database of Systematic Reviews.
Review methods: Peer-reviewed journal articles reporting interventions designed to reduce the occurrence of
musculoskeletal injuries and pain among registered nurses, published between January 2004 and June 2016,
were eligible for inclusion. Randomised and non-randomised controlled trials, as well as studies implementing
before-after designs were included. Studies investigating interventions in samples predominately comprised of
nursing aides or non-nursing personnel were excluded. Relevant articles were collected and critically analysed
using the Effective Public Health Practice Project methodology. Two reviewers independently extracted data and
performed quality appraisals for each study. A narrative synthesis of study findings was performed.
Results: Twenty studies met criteria for inclusion in the review. Types of interventions reported included: patient
lift systems (N = 8), patient handling training (N = 3), multi-component interventions (N = 7), cognitive be-
havioural therapy (N = 1), and unstable shoes (N = 1). Only two studies received a ‘strong’ quality rating ac-
cording to quality assessment criteria. One of these found no evidence for the effectiveness of patient handling
training; the other found preliminary support for unstable shoes reducing self-reported pain and disability
among nurses. Overall, evidence for each intervention type was limited.
Conclusions: There is an absence of high quality published studies investigating interventions to protect nurses
from musculoskeletal injuries and pain. Further research (including randomised controlled trials) is needed to
identify interventions that may reduce the high rates of injury and pain among nurses.

What is already known about the topic? What this paper adds

• Many nurses are required to complete physically demanding patient
care tasks that place them at increased risk of musculoskeletal in-
jury.
• Back injury is particularly prevalent among nurses, in addition to
high rates of back pain.
• Earlier systematic reviews of interventions to prevent back injury
and back pain in nurses found limited high quality evidence avail-
able.
• This updated systematic review, including studies published in the
last 12 years, found limited evidence for interventions to protect
nurses from injury.
• Only two studies received a strong quality rating according to
quality assessment criteria, and only one demonstrated a positive
effect of an intervention (unstable shoes) on participant outcomes.
• Findings suggest that increased efforts to develop and test inter-
ventions that can reduce injury and pain among nurses are required.

⁎
Corresponding author.
E-mail address: helen.harcombe@otago.ac.nz (H. Harcombe).

https://doi.org/10.1016/j.ijnurstu.2018.03.018
Received 12 December 2017; Received in revised form 21 March 2018; Accepted 21 March 2018
0020-7489/ © 2018 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/BY-NC-ND/4.0/).
A. Richardson et al.
1. Background
High rates of back injury and back pain have been consistently
documented among nurses. An investigation of the prevalence of
musculoskeletal problems in a sample of 1163 nurses working in the
United States found that 47% had experienced back problems within
the past year (Trinkoff et al., 2002). The lifetime prevalence of low back
problems is estimated to be between 35%–80% (Hignett, 1996). Fur-
thermore, back injuries occur among nurse aides, licensed practical
nurses, and registered nurses at six times the rate of other occupational
groups within the healthcare industry (Cohen-Mansfield et al., 1996).
Nurses also experience back pain more frequently than other workers
(Guo et al., 1995), in addition to disabling shoulder, knee, and wrist
pain (Harcombe et al., 2014).
The musculoskeletal injuries and pain experienced by nurses have a
number of negative implications. These include a detrimental impact on
nurse wellbeing, quality of life, and job satisfaction (Huntington et al.,
2011), and high costs resulting from lost workdays and compensation
claims (Cohen-Mansfield et al., 1996; Smedley et al., 1997). For
workers in the United States, musculoskeletal injuries are responsible
for 34% of all lost workdays and account for one in every three dollars
spent on workers’ compensation (Bureau of Labour Statistics, 2014).
There is evidence to suggest that musculoskeletal injuries may also
contribute to difficulties with the retention of nurses in the workforce.
As many as 39% of nurses reported that they planned to leave their job
within one year because of physical and psychological challenges as-
sociated with the profession, in a survey of 43,000 nurses from more
than five different countries (Aiken et al., 2001). In an anonymous
survey of 1163 registered nurses in the United States, 6%, 8%, and 11%
reported ever changing jobs for a neck, shoulder, or back problem,
respectively (Trinkoff et al., 2003).
Nurses are frequently required to perform heavy manual lifting in
order to move and reposition patients in their care. Information col-
lected for the Cultural and Psychosocial Influences on Disability study,
which included 47 samples of nurses, office workers, and other manual
workers from 18 different countries, revealed that, with the exception
of one country, the highest prevalence of heavy manual lifting was
among nurses (Coggon et al., 2012). Such lifting has been identified as
one of the biggest risk factors in the development of musculoskeletal
injuries, particularly those affecting the lower back (Retsas and
Pinikahana, 2000). In a prospective cohort study of 838 female nurses,
risk of developing low back pain across the two year follow-up period
was highest among nurses who reported frequent manual transfer, re-
positioning, and lifting of patients (Smedley et al., 1997). A systematic
review of 89 studies also concluded that nursing activities were causally
related to the experience of low back pain among nursing personnel,
with patient handling conferring the greatest risk (Yassi and Lockhart,
2013).
In addition to heavy manual lifting, a number of factors linked to
the experience of injury and pain among nurses have been identified.
Long work and overtime hours are significantly associated with sub-
sequent musculoskeletal problems, largely as a consequence of in-
creased exposure to physical demands (Trinkoff et al., 2006). Lifting in
awkward and bent postures also increases risk of back problems
(Sherehiy et al., 2004), as well as stressful working conditions (Daraiseh
et al., 2003). A number of psychological factors have been found to play
an important role, including high psychosocial demands in combination
with low job control, effort-reward imbalance, and low social support
(Bernal et al., 2015). Perceptions of physical work demands among
registered nurses in particular have been found to contribute to their
experience of inadequate sleep, pain medication use, and absenteeism
(Trinkoff et al., 2001), and a significantly increased risk of neck,
shoulder, and back musculoskeletal disorders (Trinkoff et al., 2003).
Furthermore, healthcare organisational changes, including increases in
patient loads and patient acuity over time have been associated with up
to a 3-fold increase in the neck and back problems reported by
59
International Journal of Nursing Studies 82 (2018) 58–67
registered nurses (Lipscomb et al., 2004).
Although many of the factors linked to the experience of muscu-
loskeletal injuries in nurses may be modifiable, limited evidence for
interventions that can successfully reduce these injuries has been
identified (Lagerstrom et al., 1998; Hignett, 2003). The most recent
systematic review of all available interventions to prevent both back
injuries and pain among nurses examined studies published prior to
2005 (Dawson et al., 2007). The quality of studies was poor and there
was no strong evidence to support the effectiveness of the interventions
reviewed. Results suggested that manual handling training alone was
insufficient to prevent back pain and back injury, and there was con-
flicting evidence with respect to the efficacy of interventions focused on
exercise and the provision of manual handling equipment. However,
moderate level evidence in support of multidimensional interventions
was found. The findings of this high-quality systematic review provide
an overview of interventions tested with the most robust study designs
up to 2004. However, since this time point, alternative interventions
designed to reduce musculoskeletal injuries and pain among nurses
have been investigated (Menzel and Robinson, 2006; Vieira and Brunt,
2016). Furthermore, a number of interventions have been explored
using pragmatic research designs, with interventions rolled out in
clinical practice and the effects on rates of injury, pain, and lost work
days documented. The results of such studies may highlight unique
intervention strategies that are feasible to implement and worthy of
further investigation in controlled trials.
While other recent reviews of interventions to reduce back pain and
injury among nurses have been performed, these reviews have focused
on one particular intervention type (e.g. manual handling training
(Clemes et al., 2010) or use of small aids (Freiberg et al., 2016)), have
included a broad range of occupational groups (Freiberg et al., 2016),
have examined pain only (Van Hoof et al., 2018), or have not been of a
systematic nature (Thomas and Thomas, 2014).
The objective of this study was to conduct a systematic review to
examine the effectiveness of interventions, published since 2004 (and
since the last comprehensive search (Dawson et al., 2007)), aiming to
reduce pain and musculoskeletal injuries (affecting any region of the
body) among registered nurses. In addition, the capacity of interven-
tions to reduce the costs associated with pain and injury in this group
was examined. Although many different types of nurses (including
nursing assistants and aides) are at high risk of experiencing injury and
its associated negative outcomes (Guo et al., 1995; Eriksen et al., 2004),
the focus of this review was specifically on registered nurses. Previous
reviews have not been restricted to studies of this group alone, where
unique work-related characteristics (including work-schedule and
physical and psychological demands of the job) contribute to their ex-
perience of musculoskeletal disorders (Lipscomb et al., 2002). Evidence
from this focused review may uncover interventions that are most ef-
fective for registered nurses, and the unique stressors that they face
(Hall, 2004).
2. Methods
The Effective Public Health Practice Project (EPHPP) process for
systematic reviews was followed (Thomas et al., 2004). This process
includes seven steps: 1) question formulation; 2) literature search and
retrieval; 3) identification of relevance criteria; 4) quality assessment of
relevant studies; 5) data extraction and synthesis; 6) peer review; and 7)
dissemination. Details of the systematic review process were success-
fully registered and published within the PROSPERO database (regis-
tration number CRD42017062711).
2.1. Question formulation
Adhering to the EPHPP guidelines for question formulation, our
question was whether there is now evidence for the effectiveness of
interventions that aim to reduce pain, musculoskeletal injuries, and
A. Richardson et al.
associated costs (as indicated by lost workdays and workers’ compen-
sation claims) among registered nurses.
2.2. Literature search and retrieval
As recommended by the EPHPP, seven electronic databases were
searched in order to identify relevant studies. These included:
MEDLINE, CINAHL, EMBASE, PsycInfo, Academic Search Complete,
Health Source Nursing, and the Cochrane Database of Systematic
Reviews. Searches were performed using medical subject headings, key
words, and free text words depending on the database; and were
completed in February 2017. Nursing terms were entered in the first
step; followed by musculoskeletal health outcome terms in the second
step; and a combination of these terms in the third step (see
Supplemental File 1). Each search was limited to studies published
between January 2004 and December 2016. In addition to electronic
databases; reference lists of articles identified for inclusion were
manually searched for any publications that may have been missed in
the electronic search.
All records retrieved from the searches were exported to Endnote
referencing database (Agrawal, 2007). Following this, duplicate records
were removed and the number of unique records identified. The title
and abstract of each unique record was then examined by two reviewers
(AR and BM) in order to identify potentially relevant studies. The full
text of relevant studies was then obtained and assessed for eligibility by
both reviewers.
2.3. Relevance criteria
2.3.1. Population of interest
The population of interest included registered nurses (RNs), licensed
practical nurses (LPNs), and nursing students working in hospital or
home-care settings. Studies comprised of at least 50% RNs or LPNs were
included. Studies that included both nurses (RNs and LPNs) and other
healthcare personnel (including nursing aides or assistants) were ex-
cluded unless nurses made up at least 50% of the sample or results
relating to nurses were analysed and reported separately. Where there
was insufficient information regarding the percentage of nurses in a
study, first authors were contacted via email. If contact details were out
of date or not provided, a search for current contact details was un-
dertaken. Requests for information were made to alternative authors if
the first author could not be contacted.
2.3.2. Interventions
Interventions that aimed to prevent or reduce the impact of mus-
culoskeletal injuries, pain, and/or injury-related costs in nurses were
included. Both single-component and multicomponent interventions
were considered. Interventions delivered away from the healthcare
Table 1
Quality assessment criteria.
Source: Thomas BH, Ciliska D, Dobbins M, et al. A process for systematically reviewing the literature: providing the research evidence for public health nursing
interventions. Worldviews Evid Based Nurs 2004;1:176–184. doi: 10.1111/j.1524-475X.2004.04006.x. Reproduced with permission.
Components Strong
Selection Bias Very likely to be representative of the target
population and greater than 80% participation
rate
Design Randomised controlled trial or controlled clinical
trial
Confounders Controlled for at least 80% of confounders
Blinding Blinding of outcome assessor and study
participants to intervention status and/or
research question
Data Collection Tools are valid and reliable
Withdrawals and Follow-up rate of > 80% of participants
Dropouts
International Journal of Nursing Studies 82 (2018) 58–67
setting (such as those conducted and tested in the laboratory) were
excluded.
2.3.3. Outcomes
Studies examining musculoskeletal injuries and/or musculoskeletal
pain as outcomes were eligible for inclusion. Interpretation of injury in
the present review was guided by the Medical Subject Headings (MeSH)
definition “damage inflicted on the body as the direct or indirect result
of an external force, with or without disruption of structural con-
tinuity”, as applied to the musculoskeletal system (including joints, li-
gaments, muscles, nerves, tendons, and structures that support the
limbs, neck and back). Pain was understood in relation to the MeSH
definition “an unpleasant sensation induced by noxious stimuli which
are detected by nerve endings of nociceptive neurons”. Costs associated
with modifying these outcomes were considered as a secondary out-
come, as indicated by lost or modified workdays, or the cost of workers’
compensation claims. Studies focused on the impact of interventions on
knowledge/attitudes, safety practices (handling and positioning), me-
chanical load or strain, perception of injury risk, or movement aware-
ness were excluded.
2.3.4. Study design
Randomised and non-randomised controlled trials, as well as studies
implementing before-after designs were included. The EPHPP provides
a quality assessment tool for all such designs (the Quality Assessment
Tool for Quantitative Studies), which has proven an effective measure
for use in systematic reviews (Deeks et al., 2003). Only peer-reviewed
publications (excluding conference abstracts) reporting on studies de-
signed and conducted in high-income countries with similar health care
settings to New Zealand were included, and only those published in
English. Theses describing interventions were excluded from the review
as it was expected that key findings would be published in the scientific
peer-reviewed literature.
2.4. Quality assessment
The Quality Assessment Tool for Quantitative Studies (Thomas
et al., 2004) was used to assess the methodological quality of each study
eligible for review. Each publication was assessed independently by two
reviewers (AR and BM). Following this, a consensus meeting was held
to resolve any disagreements in quality ratings. The EPHPP Quality
Assessment Tool rates studies as ‘strong’, ‘moderate’, or ‘weak’ in re-
lation to six different components, including selection bias, study de-
sign, confounders, blinding, data collection method, and withdrawals
and dropouts (see Table 1). A global rating of the study was made based
on the ratings given for each component. Studies with no weak ratings
and a minimum of four strong ratings were classified as strong; those
with four strong ratings and one weak rating as moderate; and those
Moderate Weak
Somewhat likely to be representative of the All other responses or not stated
target population and 60–79% participation
rate
Cohort analytic, case-control, cohort, or an All other designs or design not stated
interrupted time series
Controlled for 60–79% of confounders Confounders not controlled for, or not stated
Blinding of either outcome assessor or study Outcome assessor and study participants are
participants aware of intervention status and/or research
question
Tools are valid but reliability not described No evidence of validity or reliability
Follow-up rate of 60–79% of participants Follow-up rate of < 60% of participants or
withdrawals and dropouts not described
60
A. Richardson et al. International Journal of Nursing Studies 82 (2018) 58–67

with two or more weak ratings as weak (Thomas et al., 2004). Although
not included in the overall rating of studies, the integrity of interven-
tions (that is, the proportion of participants receiving the intended
duration and intensity of the intervention being tested) and the use of
appropriate statistical analysis were also considered.

2.5. Data extraction and synthesis

Two reviewers (AR and BM) completed a standardised data ex-

traction form for each publication included in the review. This form had
previously been used in a systematic review of interventions to protect
musculoskeletal health in healthcare settings (Amick et al., 2006). Data
were extracted by reading each publication and recording information
on the study design and setting, intervention characteristics, study
group, outcomes, data collection methods, and statistical analysis. In-
tervention categories were identified following the completion of data
extraction. Data extraction forms were used to complete a narrative
synthesis of results. This synthesis considered the quality rating of each
study, the number of studies investigating the same intervention, and
the consistency of findings across studies.

3. Results

3.1. Study selection

A total of 27,007 records were retrieved when combining the results

of each database search (Fig. 1). Following the removal of duplicate
records (n = 7725), 19,282 unique records were identified. Of these,
19,148 were removed based on title and abstract, leaving 134 poten-
tially relevant publications for full review. After review, 27 publications
were included and 107 publications excluded. Reasons for exclusion
included: no specific intervention being tested, a non-nursing popula-
tion was used, outcome(s) were irrelevant, country/language, not a
peer-reviewed article (e.g. news report), or because the publication was
a thesis/conference abstract.
When considering the 27 included publications, 17 authors were
contacted to ascertain the exact percentage of RNs/LPNs in the study.
Ten authors responded that 50% or more of their participants were Fig. 1. Study selection and exclusion process (PRISMA flow diagram).
RNs/LPNs, four that the study contained less than 50% RNs or LPNs
and, therefore, did not meet inclusion criteria, and three authors did not
injuries using Occupational Safety and Health Administration 200 logs.
provide a response. Therefore, 20 publications describing 20 unique
Costs (including compensation costs, lost workdays, and modified duty
intervention studies remained eligible for review.
days) were frequently measured using workers’ compensation claims
data. In contrast, the prevalence of pain was measured using ques-
3.2. Study quality
tionnaires. In instances where validity and reliability information for
questionnaires was not provided, studies received a weak rating with
The quality rating associated with each study is presented in table
respect to data collection.
format as a Supplementary file. There was initial disagreement between
With respect to intervention integrity, only three studies provided
the two reviewers with respect to the overall rating of one of the 20
information regarding the proportion of participants who received the
studies reviewed (5%). This was due to a difference in interpretation of
duration and intensity of the intervention as it was designed (Engkvist,
the study withdrawals/dropouts and was resolved through a consensus
2006a; Hodgson et al., 2013; Powell-Cope et al., 2014). For all other
meeting. Of the 20 studies, only two were classified as strong according
studies, this information was not reported and therefore it is unclear
to EPHPP quality criteria (Vieira and Brunt, 2016; Hartvigsen et al.,
whether it was measured. If few participants received the intervention
2005). Furthermore, only five studies achieved a moderate quality
as designed, then insignificant findings may reflect issues with inter-
rating (Menzel and Robinson, 2006; Kindblom-Rising et al., 2011; Theis
vention delivery rather than overall effectiveness (Thomas et al., 2004).
and Finkelstein, 2014; Caspi et al., 2013; Lim et al., 2011).
Regarding statistical analyses, the appropriateness of methods was
Many studies did not report adjusting for confounders, which had
unclear for a number of studies (Kindblom-Rising et al., 2011; Theis and
potential to explain the results found (e.g. gender, age, self-rated
Finkelstein, 2014; Hodgson et al., 2013; Kutash et al., 2009; Silverwood
health, hospital unit, number of years nursing, prior injuries).
and Haddock, 2006; Springer et al., 2009; Zadvinskis and Salsbury,
Withdrawals and dropouts were also poorly reported and this is likely
2010; Dawson et al., 2010). Furthermore, several studies provided no
because worksite populations were recruited for the majority of in-
analysis information and did not report conducting any significance
cluded studies. Worksite populations reflect open populations from
testing (Hodgson et al., 2013; Kutash et al., 2009; Silverwood and
which different individuals can contribute information before and after
Haddock, 2006; Zadvinskis and Salsbury, 2010; Guthrie et al., 2004).
the intervention. None of the studies specified whether the outcome
assessors or participants were blind to group allocation and/or the re-
search question.
The majority of studies in this review measured the prevalence of

61
 Table 2
Study characteristics and interventions tested.
Study and Quality Design
Score
Patient Lift Systems
Anyan et al. (2013) 3 Interrupted time series: pre-,
interim- and post-intervention
assessments
Dawson et al. (2010) 3 Cohort (one group compared
one year pre- and post-
intervention)
Engkvist (2006a) 3 Cross-sectional design with
concurrent control group
Guthrie et al. (2004) 3 Interrupted time series:
Implemented in 2002 and
compared with data from 2000
and 2001
Kutash et al. (2009) 3 Interrupted time series:
Implemented in 2001 (study
period 2001–2007)
Li et al. (2004) 3 Cohort (one group compared
pre- and post-intervention)
62
Silverwood and Cohort (one group compared
Haddock (2006) 3 pre- and post-intervention)
Springer et al. (2009) 3 Cohort (one group compared
pre- and during intervention)
Patient Handling
Training
Hartvigsen et al. (2005) Cohort analytic (two groups
1 compared pre- and post-
intervention)
Kindblom-Rising et al. Cohort analytic (two groups
(2011) 2 compared pre- and post-
intervention and extra control
group)
Theis and Finkelstein Cohort (one group compared
(2014) 2 pre- and post-intervention)
Multi-Component
Interventions
Caspi et al. (2013) 2 Cohort (one group compared
pre- and post-intervention)
Hodgson et al. (2013) 3 Interrupted time series:
Implemented between
2008–2011 with comparisons
pre- and post-intervention
Sample
Patient care providers (the
majority nurses) – overall
sample size not reported
Patient care providers (the
majority nurses) – overall
sample size not reported
201 nurses in intervention
hospital, 256 nurses from two
control hospitals
Registered nurses
(approximately 1000)
Approximately 5900 hospital
employees
138 nurses employed on
three hospital units
10–24 nurses working in a
hospital intensive care unit
All registered nurses and
nurse aides on four medical
and surgical units
345 home care nurses and
nurses’ aides
99 nurses in intervention
group and 77 nurses in two
control groups
55 nursing and therapy staff
374 healthcare workers (84%
staff nurses)
All employees across
Veterans Affairs medical
centers (VAMCs)
Intervention
Installation of overhead lifting systems
combined with semi-annual safe lifting
education
Workforce Initiatives Safe Handling (WISH)
program, a complete system of specialised
mechanical equipment for patient transfer
Implementation of the O’Shea No Lift System
which involved the provision of equipment
according to ward needs, training, and ongoing
monitoring
Introduction of a lift team, new mechanical
equipment, and personal lifting equipment, as
well as education provided through ‘back
school’
Implementation of a lift team, the purchase of
lifting equipment including portable ceiling
lifts, staff training in equipment and procedure
Provision of one portable full body sling lift and
two portable stand-up sling lifts
Installation of ceiling-mounted patient lifts and
a patient positioning sling
Formation of two lift teams which moved
patients hourly on each unit
Weekly education regarding body mechanics,
patient transfer, lifting techniques, and use of
low-tech ergonomic aids
Two half-day patient transfer course involving
role play
Implementation of STEPS (Safe Transfers Every
Person Succeeds) training program
Multi-component intervention targeting unit
ergonomics and safety, safe patient handling,
and worker physical fitness
Education from ‘Back Injury Resource Nurses’,
patient-handling training, and the provision of
equipment defined locally through formal
ergonomic assessments
Outcomes
Number of back injuries, workers’
compensation costs, missed work days
Number of patient handling injuries, injury-
related costs, and patient care provider
satisfaction
Use of transfer equipment, number of
injuries, pain/symptoms, and absence from
work
Number of patient handling injuries, salary
and work replacement costs, satisfaction
with intervention
Patient handling injuries, workers’
compensation costs, and lost work days
Self-reported symptoms, injury rates, lost
work days, workers’ compensation costs
Discomfort, fatigue, frustration levels, need
for medical intervention, work-related time
loss claims
Employee lifting injuries
Low back pain, care seeking due to low back
pain, satisfaction with intervention
Movement and body awareness, attitudes,
reported behaviour, strain, disorder, sick
leave
Staff injuries and injury-related costs (lost
work days)
Changes in safety/ergonomic behaviours,
social support, pain (musculoskeletal
disorders), physical activity
Number of patient handling injuries
Results
A. Richardson et al.
Significant decrease in rate of staff injuries,
number of missed workdays, and total number
of paid claims
Significant decrease in patient care provider
injuries and injury-related costs
Nurses at the intervention hospital had
significantly fewer back injuries, less pain/
symptoms, and less absence from work
compared to nurses at the control hospitals
Reduction in injury rates and associated costs
over time*
A 60% reduction in patient handling injuries for
all staff and an 82% reduction in these injuries
for registered nurses; a 97% reduction in
workers’ compensation costs; a 91% reduction
in lost workdays and a 76% reduction in
modified duty days*
Significant improvement in musculoskeletal
comfort; decrease in injury rates, adjusted lost
day injury rates, and annual workers’
compensation costs
A decrease in pain, fatigue, and frustration; a
decrease in doctors’ visits, medication use, and
time off due to injuries; and a decrease in
workers’ compensation claims*
No strong evidence for a reduction in employee
injuries related to patient handling
No significant differences between groups with
respect to low back pain and care seeking at
follow-up
Significant decrease in reported physical
disorders in the intervention group compared
with both control groups
Significant reduction in number of injuries
(although not sustained over time)
Significant increase in safe patient handling; no
significant change in pain or physical activity
Patient handling injuries in nurses declined by
more than 40% throughout the program;
infrastructure was the intervention element
related to lower injury rates*
(continued on next page)
International Journal of Nursing Studies 82 (2018) 58–67
 Table 2 (continued)

Study and Quality Design Sample Intervention Outcomes Results

Score
A. Richardson et al.

Lim et al. (2011) 2 Cohort analytic (two groups
compared two years pre- and
post-intervention)
Nelson et al. (2006) 3 Cohort (one group compared
pre- and post-intervention)
Powell-Cope et al. Interrupted time series:
(2014) 3 Implemented between
2008–2011 with comparisons
pre- and post-intervention
Warming et al. (2008) 3 Randomised controlled trial
Zadvinskis and Cohort analytic (two groups
Salsbury (2010) 3 compared pre- and post-
intervention)
1480 healthcare workers with
a previous injury from six
hospitals
825 direct patient care
nursing staff on 23 high risk
units across seven facilities
All employees across
Veterans Affairs medical
centers (VAMCs)
247 nurses working on 11
wards at a university hospital
86 nursing staff at
intervention unit, 75 nursing
staff at control unit
Mechanical lifts installed on high needs units,
staff education on body mechanics, lifting, and
patient handling procedures, as well as a ‘hands-
on’ component
A multifaceted program incorporating
ergonomic assessment, patient handling
assessment criteria and decision algorithms,
peer leaders, patient handling equipment, and a
No Lift policy
Annual safe patient handling conferences,
annual competency evaluations of safe patient
handling equipment use, and installation of safe
patient handling equipment
Two nurses from each ward were trained to
introduce a transfer technique (including use of
aids) to their colleagues; for one group this was
combined with physical fitness training
Peer coach education in proper lift equipment
use, implementation of lifting equipment, and
newly developed nursing policy
Number of repeated injuries, lost work days,
workers’ compensation claims
Injury rates, lost and modified work days, job
satisfaction, self-reported unsafe patient
handling acts, staff and patient acceptance,
program effectiveness, costs
Number of patient handling injuries
(incidence rates), organisational risk factors
Self-reported low back pain, pain level,
disability, sick leave
Patient handling injuries, costs, equipment
use
The intervention group had 38.1% lower odds
of having repeated injury compared to the
control group; significant decrease in time-loss
day per injury in intervention hospitals
Significant decrease in injury rates, modified
duty days, number of self-reported unsafe
patient handling practices, and overall injury
costs
Three organisational risk factors − bed days of
care, facility complexity level, and baseline
injury incidence −explained significant
variation in the post-intervention injury
incidence rate; several intervention components
accounted for additional variation
No statistically significant difference in low
back pain, pain level, disability, or sick leave
between nurses who received an intervention
and those in the control group
A reduction in patient-handling injuries and
costs for those receiving the multi-faceted
intervention*

Cognitive
Behavioural

63
Interventions
Menzel and Robinson Randomised controlled trial 32 registered nurses and Stress and pain management sessions led by Self-reported pain, stress, disability, mood Pain intensity scores decreased in the
(2006) 2 nursing assistants with a psychologists intervention group (not significant) yet stress
history of back pain scores significantly increased relative to the
control group

Unstable Shoes
Vieira and Brunt (2016) Randomised controlled trial 20 matched female registered Unstable shoes to wear for one month during Self-reported low back pain and disability The intervention group reported significantly
1 nurses with low back pain work hours lower levels of pain and disability at follow-up

Note. *Statistical significance not reported; Quality key: 1 = strong rating, 2 = moderate rating, 3 = weak rating.
International Journal of Nursing Studies 82 (2018) 58–67
A. Richardson et al.
3.3. Study characteristics
Characteristics of studies included in the review are presented in
Table 2, with studies grouped according to the intervention type under
investigation.
Eight studies described interventions that involved the im-
plementation of patient lift systems (mechanical lifts and equipment
designed to aid patient transfer). Each of these studies, with the ex-
ception of Springer et al. (2009), reported a positive effect of the in-
tervention on nurse injuries and/or pain, and injury-related costs.
However, none of the studies utilised a robust design, and all received
weak ratings based on EPHPP quality criteria. No randomised con-
trolled trials (RCTs) of lift systems were identified and the only study
with a comparison group employed a cross-sectional design (Engkvist,
2006b). Therefore, no evidence to suggest that patient lift systems are
effective at preventing injuries or pain among nurses was found.
Three studies focused specifically on improving patient handling
techniques. Hartvigsen et al. (2005) received a strong quality rating and
found no significant difference in low back pain between nurses who
received an intensive educational intervention (including weekly edu-
cation in body mechanics, patient transfer, and lifting techniques) and
nurses in a control group who received a one-time instructional
meeting. Conversely, Kindblom-Rising et al. (2011) found that nurses
who participated in a two half-day patient transfer course reported a
significant decrease in physical disorders at one year follow-up com-
pared to nursing staff in two control groups. This study received a
moderate rating, as did a publication by Theis and Finkelstein (2014),
which also documented a significant reduction in injuries in the short-
term following implementation of a safe patient-handling program.
However, the reduction in injuries was not significantly different from
baseline at 2.5 years after program implementation, and the sample size
was small (n = 55). Taken together, these findings suggest that inter-
ventions to improve patient handling may be beneficial, but further
research is needed.
We identified seven studies testing multi-component interventions
designed to target injuries and pain among nurses. These interventions
combined a number of different approaches, such as ergonomic aids,
mechanical equipment, patient handling training, and physical activity.
None of the studies received a strong rating, but two received a mod-
erate rating. One of these found no effect of an intervention designed to
address workplace ergonomics and safety, patient handling, and worker
physical fitness on musculoskeletal pain or physical activity, although
there were improvements in patient handling and safety practices
(Caspi et al., 2013). In contrast, the other moderate quality study
documented a positive effect of a multi-component intervention on
nurse injuries. Lim et al. (2011) compared nurses from three hospitals
receiving an injury prevention program (including engineering and
administrative controls as well as staff education on anatomy, injuries,
body mechanics, personal health, lifting and patient handling proce-
dures, and patient handling algorithms) with nurses in three control
hospitals. Results found that nurses in the intervention group had 38%
lower odds of experiencing repeated injury compared to those in the
control group. Furthermore, data comparing intervention and control
hospitals 2 years pre- and post-intervention showed that time off from
work significantly decreased among nurses at the intervention hospi-
tals. While two other studies also made use of a comparison group
(Zadvinskis and Salsbury, 2010; Warming et al., 2008), they received
weak quality ratings because of low participation and high loss to
follow-up rates. Therefore, the evidence for multi-component inter-
ventions is limited and conflicting.
Two other studies investigated the effectiveness of a cognitive-be-
havioural intervention and nurses wearing shoes designed to be un-
stable, respectively. Menzel and Robinson (2006) found that nurses
randomly assigned to receive a 6-week cognitive behavioural therapy
(CBT) program reported reduced pain in comparison to nurses ran-
domly assigned to a waitlist control group. Although the reduction in
64
International Journal of Nursing Studies 82 (2018) 58–67
pain represented a large effect, it was not statistically significant (likely
due to small sample size, n = 32). Furthermore, nurses who received
the intervention reported a significant increase in perceived stress
scores from baseline to 6-week follow-up. These findings suggest that
the capacity of CBT to reduce injury and pain in nurses is yet to be
demonstrated. Vieira and Brunt (2016) tested the efficacy of unstable
shoes in reducing low back pain and disability among 20 registered
nurses in a randomised controlled trial (RCT) that received a strong
rating according to EPHPP quality criteria. Nurses assigned to wear the
shoes for one month reported significantly less pain and disability at 4
and 6-week follow-up relative to the control group. Although this study
is limited by reliance on self-report measures and a small sample size,
the results suggest that unstable shoes may be a promising and cost-
effective intervention strategy.
4. Discussion
This systematic review aimed to identify new evidence for inter-
ventions to reduce the high prevalence of pain and musculoskeletal
injuries in registered nurses. Twenty studies were identified for inclu-
sion. However, the majority of reported studies were found to have
methodological limitations that affected their overall quality rating.
Only two studies received a ‘strong’ quality rating according to EPHPP
assessment criteria. Given that these ratings applied to two separate
types of intervention (patient handling training and unstable shoes)
(Vieira and Brunt, 2016; Hartvigsen et al., 2005), and that one found no
evidence for intervention effectiveness (Hartvigsen et al., 2005), it is
not possible to identify a well-supported intervention among those re-
viewed.
Intervention types identified in this review included: patient lift
systems, patient handling training, multi-component interventions,
cognitive behavioural therapy, and unstable shoes. A number of other
reviews of studies investigating interventions to prevent musculoske-
letal injuries and pain in nurses have focused specifically on one of
these intervention types (Clemes et al., 2010; Freiberg et al., 2016).
However, a recent systematic review of all interventions for low back
pain among nurses identified 14 studies investigating manual handling
training, multidimensional interventions, stretching exercises, and
stress management (Van Hoof et al., 2018). Two of these categories
were not identified in the current review, which is attributable to our
focus on interventions for registered nurses. Nevertheless, similar con-
clusions were drawn, with no strong evidence of efficacy for any in-
tervention in preventing or treating low back pain among nurses. In the
earlier review of all interventions to prevent back injury and pain
among nurses, conducted by Dawson et al. (2007), exercise, manual
handling training, lumbar supports, stress management, and multi-
dimensional interventions were identified. Again, no strong evidence
for any intervention type was found.
A single study testing the efficacy of unstable shoes at reducing pain
and disability in nurses was identified. This RCT received a strong
quality rating and found preliminary support for the shoes, which work
by activating muscles that enhance postural control (Vieira and Brunt,
2016). The study was limited by a small sample size and results are yet
to be replicated in a larger population of nurses. However, a separate
RCT also demonstrated that wearing unstable shoes over a 6 week
period significantly decreased low back pain among hospital workers
more generally (Armand et al., 2014), suggesting that the shoes may be
an effective intervention strategy.
The methods used to investigate the efficacy of patient lift systems
to assist nurses prevent any conclusions from being made; seven of
eight studies testing this type of intervention did not have a comparison
group. The majority of these studies examined one population pre- and
post-intervention implementation, with different individuals able to
contribute information depending on who was currently employed at
each assessment point. Consequently, it was difficult for potential
confounders to be controlled for and information regarding
A. Richardson et al.
withdrawals and those lost to follow-up across the study period could
not be provided.
Other reviews have found conflicting evidence for the provision of
manual handling equipment among nurses. Dawson et al. (2007) found
that one RCT provided evidence for the capacity of mechanical and
other assistive patient handling equipment to improve fatigue, back and
shoulder pain, safety, and physical discomfort (although not injury
rates) in nurses (Yassi et al., 2001), while two non-randomised trials
found no effect of this type of intervention (Knibbe and Friele, 1999;
Smedley et al., 2003). A more recent review estimated that the use of
lifting devices among nurses could lead to a potential reduction in low
back pain prevalence of 41.9% and a reduction in injury claims of up to
5.8 per 100 work-years, using available data from observational and
experimental studies (Burdorf et al., 2013). However, predictions were
made using the results of few longitudinal studies, and only one was a
RCT. The authors acknowledged the difficulty associated with utilising
experimental designs when investigating implementation of lifting de-
vices in the workplace but recommended that measurement of changes
in health outcomes be accompanied by measurement of changes in
mechanical exposure over sufficiently long periods of follow-up.
Conflicting evidence for patient handling training and multi-com-
ponent interventions was found. Hartvigsen et al. (2005) received a
strong quality rating and did not find a significant impact of patient
handling training on low back pain among nurses, while two moderate
quality publications found at least short-term support for this form of
intervention at reducing injuries (Theis and Finkelstein, 2014) and self-
reported physical disorders (Kindblom-Rising et al., 2011). Previous
reviews have not found evidence that manual handling training alone
can reduce musculoskeletal pain or injury (Dawson et al., 2007), in-
cluding those examining the effectiveness of these interventions for
health care providers (Hignett, 2003), as well as a systematic review of
studies providing manual handling training across a broad range of
industries (Clemes et al., 2010). Instead, multi-component interven-
tions that are based on a risk assessment and tailored to the demands of
the work environment are recommended. In their systematic review,
Dawson et al. (2007) found moderate level evidence for these inter-
ventions, particularly in reducing low back pain among nurses. How-
ever, the present review found that only two of seven multi-component
intervention studies were of moderate quality, with one documenting
no effect on musculoskeletal pain (Caspi et al., 2013) and the other
finding lower odds of repeated injury and a decrease in lost workdays
(Lim et al., 2011). An inherent problem with evaluating this type of
intervention is identifying the factor(s) responsible for improvements in
outcomes.
Limited evidence was found to support the use of CBT to reduce
pain and injury in nurses, with only one study identified for this review.
Although the study was of moderate quality, the sample size was small
and the follow-up rate low, limiting the detection of any significant
effects (Menzel and Robinson, 2006). While CBT has proven effective at
reducing perceived disability and pain intensity among individuals with
chronic low back pain (Smeets et al., 2006), further research involving
larger samples will be necessary in order to determine if CBT can also
benefit nurses.
4.1. Strengths
Our review adds to a growing body of literature reviewing inter-
ventions to reduce musculoskeletal injuries and pain among nurses
(Dawson et al., 2007; Clemes et al., 2010; Freiberg et al., 2016; Van
Hoof et al., 2018; Thomas and Thomas, 2014). However, the focus of
this review is different in several key ways. All other reviews have in-
cluded heterogeneous samples of nurses (registered nurses, nursing
aides, nursing assistants, nursing students and home care workers). By
focusing specifically on registered nurses, it was possible for us to de-
termine whether there are interventions most beneficial for this parti-
cular population and the unique challenges they experience (Hall,
65
International Journal of Nursing Studies 82 (2018) 58–67
2004). Other reviews to date have also focused on reviewing a specific
intervention type (Clemes et al., 2010; Freiberg et al., 2016; Burdorf
et al., 2013) as opposed to all available interventions, have been re-
stricted to controlled trials only (Dawson et al., 2007; Van Hoof et al.,
2018), or have not utilised a systematic approach (Thomas and Thomas,
2014). Unlike previous reviews, we examined injuries and pain af-
fecting any region of the body, given that the experience of these out-
comes is not restricted to the back (Trinkoff et al., 2002). Therefore, this
systematic review provides a comprehensive overview of the most re-
cent interventions to prevent musculoskeletal injuries and pain in re-
gistered nurses.
4.2. Limitations
There are several limitations associated with this systematic review.
First, the review only considered published studies. The findings of
published studies may systematically differ to those of unpublished
studies, introducing bias. Second, the focus of the review was on re-
gistered nurses, with studies including less than 50% RNs excluded.
While this increased the homogeneity of the population under review,
the results cannot be generalised to nursing assistants and aides, who
are also known to experience high rates of injury and low back pain
(Hignett, 1996). Similarly, the review excluded studies from low-in-
come countries, where differences in work settings may exist. This may
have led to potentially effective intervention techniques being omitted.
Third, three studies were excluded from this review due to a lack of
response from study authors regarding sample characteristics. These
studies may have been able to provide additional evidence, potentially
leading to different conclusions regarding the efficacy of each inter-
vention type. Finally, a quality assessment tool that allowed for the
inclusion of studies without a comparison group was used. Although
this increased the number of possible studies for review, limited con-
clusions could be drawn from their findings.
4.3. Implications
This review highlights an absence of research evidence in support of
specific interventions that can reduce injuries and pain among regis-
tered nurses, despite the well-documented prevalence of these problems
(Harcombe et al., 2014). In addition to having direct costs in the form of
workers’ compensation claims and absenteeism, musculoskeletal pro-
blems are associated with difficulties in staff retention (Aiken et al.,
2001). Therefore, efforts to prevent injuries and pain are of great im-
portance, particularly in light of the nursing shortage, which is antici-
pated to worsen under the burden of an ageing population (Oulton,
2006). The limited number of RCTs highlights potential difficulties in
implementing such designs in the healthcare setting, and reviews fo-
cusing exclusively on this type of study design may fail to identify in-
terventions with potential to be both feasible and effective in clinical
practice. Nevertheless, it is important that future intervention studies
(whether observational or experimental) measure changes in health
outcomes alongside changes in intervention exposure, over adequate
periods of follow-up (Burdorf et al., 2013). Efforts should be made to
attain representative and adequately powered samples. The use of valid
and reliable outcome measures and the complete reporting of partici-
pation rates, data analysis, and results are also recommended.
5. Conclusion
This systematic review of up-to-date evidence for interventions
designed to reduce pain, musculoskeletal injuries, and associated costs
in nurses demonstrates that there is an absence of high quality studies
in this area. As a result, it is not possible to identify any intervention
with a strong support base. Further research is needed in order to de-
termine the effectiveness of different intervention types. This would
help to reduce confusion regarding conflicting findings on the efficacy
A. Richardson et al.
of patient handling training and multi-component interventions, and
could provide further support for CBT and unstable shoes as effective
intervention approaches.
Competing interests
The authors have no competing interests to declare.
Funding
The authors have no external funding to declare.
Appendix A. Supplementary data
Supplementary data associated with this article can be found, in the
online version, at https://doi.org/10.1016/j.ijnurstu.2018.03.018.
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