International Journal of Nursing Studies 52 (2015) 635–648

Contents lists available at ScienceDirect

International Journal of Nursing Studies

journal homepage: www.elsevier.com/ijns

Review

Work-related psychosocial risk factors and musculoskeletal

disorders in hospital nurses and nursing aides:
A systematic review and meta-analysis
Dinora Bernal a,b, Javier Campos-Serna b,c,d, Aurelio Tobias e,
Sergio Vargas-Prada b,d, Fernando G. Benavides b,d, Consol Serra b,d,f,*
a
Faculty of Nursing Care, University of Panama, Panama
b
CiSAL – Center for Research in Occupational Health, Universitat Pompeu Fabra, Barcelona, Spain
c
Area of Public Health and Preventive Medicine, University of Alicante, Alicante, Spain
d
CIBER Epidemiology and Public Health (CIBERESP), Spain
e
Institute of Environmental Assessment and Water Research (IDAEA), Spanish Council for Scientific Research (CSIC), Spain
f
Occupational Health Service, Parc Salut MAR, Barcelona, Spain

A R T I C L E I N F O A B S T R A C T

Article history: Objectives: To estimate the association between psychosocial risk factors in the workplace
Received 25 January 2014 and musculoskeletal disorders (MSD) in nurses and aides.
Received in revised form 31 October 2014 Design: Systematic review and meta-analysis.
Accepted 4 November 2014
Data sources: An electronic search was performed using MEDLINE (Pubmed), Psychinfo,
Web of Science, Tripdatabase, Cochrane Central Controlled Trials, NIOSHTIC and Joanna
Keywords:
Briggs Institute of Systematic Reviews on Nursing and Midwifery, to identify observational
Musculoskeletal disorders
studies assessing the role of psychosocial risk factors on MSD in hospital nurses and
Nurse
Hospital nursing aides.
Psychosocial factors Review methods: Two reviewers independently assessed eligibility and extracted data.
Workplace Quality assessment was conducted independently by two reviewers using an adapted
Systematic review version of the Standardized Quality Scale. Random-effects meta-analysis was performed
Meta-analysis by subsets based on specific anatomical site and the exposure to specific psychosocial risk
factors. Heterogeneity for each subset of meta-analysis was assessed and meta-
regressions were conducted to examine the source of heterogeneity among studies.
Results: Twenty-four articles were included in the review, seventeen of which were
selected for meta-analysis. An association was identified between high psychosocial
demands–low job control with prevalent and incident low back pain (OR 1.56; 95% CI
1.22–1.99 and OR 1.52; 95% CI 1.14–2.01, respectively), prevalent shoulder pain (OR 1.89;
95% CI 1.53–2.34), prevalent knee pain (OR 2.21; 95% CI 1.07–4.54), and prevalent pain at
any anatomical site (OR 1.38; 95% CI 1.09–1.75). Effort-reward imbalance was associated
with prevalent MSD at any anatomical site (OR 6.13; 95% CI 5.32–7.07) and low social
support with incident back pain (OR 1.82; 95% CI 1.43–2.32). Heterogeneity was generally
low for most subsets of meta-analysis.

* Corresponding author at: Center for Research in Occupational Health – Universitat Pompeu Fabra, Carrer Doctor Aiguader 88, 08003 Barcelona, Spain.
Tel.: +34 933160875; fax: +34 933160410.
E-mail address: consol.serra@upf.edu (C. Serra).

http://dx.doi.org/10.1016/j.ijnurstu.2014.11.003
0020-7489/ß 2014 Elsevier Ltd. All rights reserved.
636 D. Bernal et al. / International Journal of Nursing Studies 52 (2015) 635–648
Conclusion: This meta-analysis suggests that psychosocial risk factors at the workplace are
associated with MSD in hospital nurses and nursing aides. Although most preventive
strategies at the workplace are focused on ergonomic risk factors, improving the
psychosocial work environment might have an impact on reducing MSDs.
What is already known about the topic?
 Musculoskeletal disorders (MSD) are one of the leading
causes of disability in hospital nurses and nursing aides.
 Traditionally, studies on risk factors for MSD have
focused on physical activities like manual handling,
and individual characteristics, such as sex and age.
 Recently, a growing body of evidence suggests that
organizational factors might play an important role in
the occurrence of MSD in nurses and aides.
What this paper adds
 Despite the small number of longitudinal studies
available, our findings provide consistent evidence of
an association between exposure to work-related
psychosocial factors and MSD in hospital nurses and
aides.
 Interventions to reduce MSD in hospitals should take
into account not only ergonomics, but also the improve-
ment of organizational aspects of the work environment.
1. Introduction
Work-related musculoskeletal disorders (MSD) are
defined as symptoms caused or aggravated by occupation-
al risk factors, including discomfort, damage or persistent
pain in body structures, such as muscles, joints, tendons,
ligaments, nerves, bones, and the circulatory system
(Barboza et al., 2008; Cherry et al., 2001; Kee et al.,
2007; Trinkoff et al., 2002). MSD are the most common
health problem associated with work in Europe, affecting
millions of workers. It has been estimated that 25% of
European workers complain of back pain and 23% of
muscle aches. MSD are the main cause of sickness absence
in western European countries (Murray et al., 2012), and in
the United States and Canada (Punnett and Wegman,
2004). In Europe, costs due to MSD represent approxi-
mately 2 per cent of their Gross Domestic Product (GDP)
(Bevan et al., 2009), without considering productivity
losses and social costs (Choobineh et al., 2010; Menzel,
2007; Podniece and Taylor, 2008). Furthermore, MSD is
also one of the main causes of sickness absence among
hospital nurses and nursing aides, although underreport-
ing is common (Menzel, 2008).
Factors associated with MSD include individual char-
acteristics, such as age and sex, occupational risk factors
and non-work related exposures. Physical risk factors that
arise from a worker’s tasks (e.g. physical demands,
handling loads, repetitive movements or vibration) are
well established workplace risk factors for the occurrence
of MSD. However, there is some evidence that occupational
psychosocial risk factors, such as high psychosocial
ß 2014 Elsevier Ltd. All rights reserved.
demands, low job control or low social support, could
also have a role (European Agency for Safety and Health at
Work, 2007; Magnago et al., 2007). Hospital nurses and
nursing aides are occupational groups especially at risk of
developing MSD (Magnago et al., 2007; Solidaki et al., 2010).
The prevalence of MSD in nursing professionals has been
documented in different studies (Choobineh et al., 2010;
Smith et al., 2003) and varies across countries (Coggon et al.,
2013). Karahan et al. found that hospital nurses and nursing
aides had the highest prevalence of MSD (77.1%) in a sample
of Turkish health care workers (Karahan et al., 2009). In
Norway the prevalence of MSD in nursing aides has been
found to be as high as 89% (Willy, 2003), whereas in Japan it
is much lower at around 37% (Matsudaira et al., 2011).
Several studies have shown a high risk of developing neck
and low back pain in hospital nurses, attributed to both
physical and psychosocial factors at work, such as shift
work, long hours at work (Magnago et al., 2007; Menzel,
2007; Trinkoff et al., 2002) and the stress related to patient’s
management (Solidaki et al., 2010).
Although some previous systematic reviews have
reported an association between psychosocial risks factors
in the workplace and MSD in hospital nurses and nursing
aides, to our knowledge no meta-analysis has yet been
published. Thus, the aim of our study was to evaluate and
quantify the association between exposure to psychosocial
factors in the workplace and MSD in nurses and nursing
aides in hospital settings.
2. Methods
2.1. Search strategy
An electronic search was carried out using MEDLINE
(Pubmed), Psychinfo, Web of Science, Tripdatabase,
Cochrane Central Controlled Trials, NIOSHTIC and Joanna
Briggs Institute of Systematic Reviews on Nursing and
Midwifery. Our search strategy was applied similarly to all
databases and combined four blocks of keywords intended
to capture different aspects of our review: (1) the outcome
(prevalence and incidence of MSD), (2) the study popula-
tion (nurses and nursing aides), (3) exposure (psychosocial
risk factors, including high psychosocial demands/low job
control, low social support (Karasek et al., 1981) and
effort-reward imbalance (Siegrist et al., 1997)), and (4)
occupational setting (hospital). The search terms used
were: for study population and occupational setting
‘‘(((((‘‘nurses’’[MeSH Terms] NOT ‘‘breast feeding’’[MeSH
Terms] OR nurse[Text Word]) OR (‘‘personnel, hospital’’
[MeSH Terms] OR hospital staff[Text Word])) OR aides
[All Fields]) OR (‘‘nursing staff’’[MeSH Terms] OR ‘‘nur-
ses’’[MeSH Terms] OR nursing personnel[Text Word]))’’;
for psychological risk factors ‘‘((((‘‘psychosocial factor-
 D. Bernal et al. / International Journal of Nursing Studies 52 (2015) 635–648
s’’[All Fields] OR (‘‘workplace’’[MeSH Terms] OR work-
place[Text Word])) OR (job[All Fields] AND (‘‘sprains and
strains’’[MeSH Terms] OR strain[Text Word]))) OR (‘‘social
support’’[MeSH Terms] OR social support[Text Word])) OR
((‘‘work’’[MeSH Terms] OR work[Text Word]) AND (‘‘orga-
nisations’’[MeSH Terms] OR organisational[Text Word])
AND factors[All Fields])))’’; and for MSD ‘‘(((((((musculos-
keletal[All Fields] OR (‘‘upper extremity’’[MeSH Terms] OR
upper limbs[Text Word])) OR ‘‘wrist injuries’’[MeSH
Terms]) OR (‘‘elbow’’[MeSH Terms] OR ‘‘elbow join-
t’’[MeSH Terms] OR elbow[Text Word])) OR (‘‘shoulder
pain’’[MeSH Terms] OR shoulder pain[Text Word])) OR
(‘‘neck pain’’[MeSH Terms] OR neck pain[Text Word])) OR
(‘‘low back pain’’[MeSH Terms] OR low back pain[Text
Word])) OR (‘‘back pain’’[MeSH Terms] OR back pain[Text
Word])). Also, the reference lists of papers which fulfilled
our inclusion criteria were reviewed to identify additional
studies not included in our electronic search.
2.2. Study selection and eligibility criteria
Observational studies (cohort, case-control or cross-
sectional), published in English or Spanish between
January 2001 and March 2014, were included if they
assessed the association between MSDs and psychosocial
risk factors at the workplace in hospital nurses and nursing
aides. Studies were excluded if: (i) they were in a different
language than English or Spanish, (ii) the study population
was nursing students, or (iii) a wide range of hospital
workers and occupations were included, but data for
hospital nurses or nursing aides were not analyzed
separately.
After excluding duplicates, a total of 3202 citations
were obtained from the electronic search. All citations
were reviewed by title, and when was necessary, by
abstract. Ninety-one potential publications were identified
and for all of them full text were obtained. Those studies
were reviewed by two independent researchers (DB and
JC). The degree of agreement (kappa index) between the
two reviewers was 80.2%. Disagreements (20% of the 91
identified publications) were resolved by a third reviewer
(SVP/CS) who made the final decision. Twenty-six pub-
lications (all in English) which met the inclusion criteria
were included for quality assessment. Fig. 1 shows the flow
chart of study selection.
2.3. Quality assessment and extraction
The methodological quality of the 26 studies that met
the inclusion criteria was assessed independently by two
reviewers (DB and JC). As has been done in previous
systematic reviews for meta-analysis (Bongers et al., 2002;
Gershon et al., 2007), we used an adapted version of the
Standardized Quality Scale developed by van der Windt
et al. (2000). This scale included 15 items grouped into
5 areas: (1) study objective, (2) study population, (3)
measurement of psychosocial exposure, (4) outcome, and
(5) data analysis and presentation. Each item was rated as
‘‘positive’’ (when requirement was met), ‘‘negative’’ (when
requirement was not met) or ‘‘unclear’’ (unsure if
requirement was met). A score was obtained for each
637
study by the sum of all positive responses (1 point each
item). Studies were considered as high-quality when the
score was higher than 80% of the maximum possible score,
intermediate quality when the score was between 70% and
79%, and low-quality when it was below 70%. Two studies
were of low quality, and were excluded (Dundar and
Ozmen, 2010; Fonseca and Fernandez, 2010).
The following general and methodological information
was obtained from each of the 24 included papers (Table
1): authors’ last names, country, year of publication,
epidemiological design, study population, sample size,
response rate, mean age, and work-related physical
demands. Moreover, characteristics of the exposure to
psychosocial risk factors (high psychosocial demands, low
job control, low social support from co-workers and
supervisors, and effort-reward imbalance) and informa-
tion related to the outcome (prevalence of pain at any
anatomical site, prevalence and incidence of back pain,
prevalence of neck pain, prevalence of shoulder pain and
prevalence of knee pain) were collected. Also, information
about adjustment variables and epidemiologic measures of
association (prevalence ratio (PR), hazard ratio (HR) or
odds ratio (OR)), and their 95% confidence interval (95% CI)
were identified from each paper.
2.4. Meta-analysis
From the 24 studies included in the review, we
excluded for meta-analysis one study where the 95% CIs
were not provided (Camerino et al., 2001), one cohort
(Herin et al., 2011) and four cross-sectional studies
(Carugno et al., 2012; Sorour and El-Maksoud, 2012;
Surawera et al., 2012; Violante et al., 2004) where different
psychosocial exposures and/or outcomes were assessed;
and one cohort study because hazard ratios were reported
as measures of association (Smedley et al., 2003).
Therefore, 17 studies were considered for meta-analysis,
which was carried out using version 11 of Stata software
(StataCorp, 2009).
Random effects models were estimated using the
method proposed by DerSimonian and Laird (1986), and
the included studies were grouped into nine subsets
according to their epidemiological design, the type of
psychosocial exposure (high psychosocial demands/low
job control, low social support and effort-reward imbal-
ance) and the main outcome (prevalent pain at any
anatomical site, prevalent and incident back pain, preva-
lent neck pain, prevalent shoulder pain and prevalent knee
pain). Forest plots of meta-analysis were depicted for each
of the nine subsets of studies: (1) exposure to high
demands/low job control with prevalence of low back
pain; (2) exposure to high demands/low job control with
prevalence of neck pain; (3) exposure to high demands/low
job control with prevalence of shoulder pain; (4) exposure
to high demands/low job control with prevalence of knee
pain; (5) exposure to high demands/low job control with
prevalence of pain at any anatomical site; (6) exposure to
low social support with prevalence of pain at any
anatomical site; (7) exposure to effort reward imbalance
with prevalence of pain at any anatomical site; (8)
exposure to high demands/low job control with incidence
638 D. Bernal et al. / International Journal of Nursing Studies 52 (2015) 635–648

Records idenfied through Addional records idenfied

database searching through other sources
(n = 5,788 ) (n = 6)

Records aer removal of duplicates

(n =3,102 )
Excluded based on tle or abstract
(n=3,011):
• Not relevant (n= 2,924)
• Review (n = 87)
Full-text arcles assessed for eligibility
(n =91)
Excluded (n = 65):
• Other occupaon than nurse (n=16)
• Nursing students (n=1)
• Not measuring associaon between
MSD and psychosocial factors (n=34)
Studies included in
qualitave assessment
(n = 26)

Excluded (n = 2):
• Low quality (score <70%) (n=2)

Studies included in the review

(n = 24) Excluded (n=7):
• 95% CI not provided (n = 1)
• Variables available for the matching
(n=5)
• Reported hazard rao (n=1)
Studies included in quantave
synthesis (meta-analysis)
(n = 17)

Fig. 1. Flow chart for selection of included studies.

of low back pain; and (9) exposure to low social support
with incidence of back pain. The outcome ‘‘pain at any
anatomical site’’ was considered for studies where
musculoskeletal pain was reported without distinguishing
a specific anatomical site.
A pooled effect size (OR) and its 95% CI were reported
for each subset. The Cochrane Q test was used to test for
heterogeneity and the I2 statistic (the percentage of the
total variability between studies due to heterogeneity) to
quantify it (Huedo-Medina et al., 2006). The I2 takes values
between 0% and 100%, and a value of 0% indicates absence
of heterogeneity. I2 was interpreted based on Higgins and
Thompson classification (Huedo-Medina et al., 2006);
percentages of 25%, 50% and 75% were considered as low,
intermediate and high heterogeneity, respectively. A cut-
off of p  0.1 was considered to determine if heterogeneity
was statistically significant.
2.5. Meta-regression
Meta-analysis regression (or meta-regression) is an
extension to standard meta-analysis that investigates the
extent to which statistical heterogeneity between studies
can be attributed to one or more specific characteristics of
the studies. A meta-regression was performed for those
subsets where the heterogeneity was statistically signifi-
cant. Sample size, response rate and mean age where
considered as potential study characteristics that might
partially explain most of the observed heterogeneity.
Associations between those variables and outcomes (log
OR) were evaluated in univariate meta-regression models.
3. Results
3.1. Systematic review
Of the 24 intermediate and high quality studies
included in the review (Table 1), 18 had a cross-sectional
design (Alexopoulos et al., 2003, 2006; Bos et al., 2007;
Carugno et al., 2012; Choobineh et al., 2010; De Souza
Magnago et al., 2010; Golabadi et al., 2013; Hoe et al.,
2012; Mehrdad et al., 2010; Sembajwe et al., 2013; Simon
et al., 2008; Smith et al., 2006; Sorour and El-Maksoud,
2012; Stone et al., 2007; Surawera et al., 2012; Violante
Table 1
Characteristics of included studies and association between exposure to psychosocial factors at work and musculoskeletal disorders in nursing professionals.

Study ID, Design, Follow-up Study participants, Measure Outcome Analysis, Quality % Exposure Anatomic OR 95% CI
Country period, Response Sample size, (psychosocial measured Adjustment score (QS) variables site
rate Mean age factors and MSD) variables

Alexopoulos Cross sectional Nurses and aides Karasek model Musculoskeletal Logistic regression, 11/13 84.6 High job demands Back 1.50 0.92–2.45
et al. (2003) November from 6 hospital Nordic complaints of the adjusted for age, High job demands Neck 1.93 1.24–2.99
Greece 2000 and March n = 420 Questionnaire back, neck, or gender, physical High job demands Shoulder 1.84 1.21–2.81
2001 37 years shoulder were demands Low supervisor Back 1.13 0.69–1.85
84% defined as pain in support Neck 1.68 1.08–2.60
the past 12 Low supervisor Shoulder 1.45 0.95–2.22
months support
Low supervisor

D. Bernal et al. / International Journal of Nursing Studies 52 (2015) 635–648

support

Alexopoulos Retrospective Nurses and aides Karasek model Back pain in the Logistic regression, 11/14 78.6 High job demands Back 1.66 1.10–2.50
et al. (2006) cohort n = 393 Nordic past 12 months adjusted for
The November 2000 to 38 years Questionnaire physical demands
Netherlands March 2001
and Greece 64%

Alexopoulos Cross sectional Nurses Karasek model Musculoskeletal Logistic regression, 10/13 76.9 High job demands Knee 4.60 1.57–13.50
et al. (2011) September to n = 448 Nordic complaints low adjusted for age, Low co-workers Knee 3.13 1.12–8.78
Greece December 2007 38 years Questionnaire. back pain and knee gender, physical support
78% pain in the past demands
12 months

Bos et al. Cross sectional Nurses from Copenhagen Complaints during Logistic regression 11/13 84.6 Job demands Back 1.09 1.03–1.14
(2007) January 2001 to 8 hospitals, Psychosocial the past year. multivariate model, Support Back – –
The December 2003 different areas. Questionnaire Low back, neck or adjusted for Control Back 1.00 0.96–1.04
Netherlands 63% n = 3169 Nordic shoulder physical demands Job demands Neck 1.01 0.97–1.06
37 years Questionnaire Support Neck 1.02 0.97–1.08
Control Neck 1.03 0.99–1.07

Camerino Prospective cohort Nurses from Adaptation of Back pain Logistic regression 11/14 78.6 High demands/low Back 12.43 0.0004a
et al. (2001) Period not specified different Karasek model experienced adjusted age, sex, decision
Italy 87% departments (MONICA study); during the last year physical demands Low decision/low
n = 1159 validated Italian. demands
35 years Ergonomics High decision/high
questionnaire demands
High decision/low
demands

Carugno Cross sectional Nurses from public Adaptation of Pain at three or Logistic regression, 12/13 92.3 Job dissatisfaction Multi-site 1.50 0.86–2.63
et al. (2012) May 2008 and hospitals in Brazil Karasek model more sites in past adjusted for age, (Italy) 2.55 0.63–10.35
Brazil and Italy March 2010 and Italy (CUPID Study month sex, physical Multi-site
96% (Brazil) n = 751 questionnaire) demands (Brazil)
76% (Italy) (50% <40 years) Nordic
Questionnaire

Choobineh Cross sectional Operation room Job Content Musculoskeletal Logistic regression 11/13 84.6 Perceived job Back 2.25 1.26–4.01
et al. (2010) February to nurse Questionnaire problem in adjusted for age, demands high/low Shoulder 1.68 1.04–2.73
Iran September 2007 n = 375 (JCQ) different body physical demands demands
80% 34 years Nordic regions in the

639
Questionnaire past month
Table 1 (Continued )

640
Study ID, Design, Follow-up Study participants, Measure Outcome Analysis, Quality % Exposure Anatomic OR 95% CI
Country period, Response Sample size, (psychosocial measured Adjustment score (QS) variables site
rate Mean age factors and MSD) variables

De Souza Cross sectional Nurses and aides Job Content Experienced some Logistic regression 10/13 76.9 Demands-control Back 1.36 0.72–2.60
Magnago March–September n = 491 Questionnaire pain or discomfort adjusted for age, Low demands Neck 1.43 0.75–2.73
et al. (2010) 2006 38 years (JCQ) during last year smoking, time on (reference Shoulder 1.97 1.07–1.64
Brazil 93% Nordic the job, category) Legs 1.51 0.83–2.76
Questionnaire physical demands Ankles 2.05 1.05–4.02
(Brazilian).

Golabadi Cross sectional Nursing Job Content Pain in past Logistic regression, 11/13 84.6 High demands High Lower back 1.73 1.18–2.53
et al. (2013) 2011 professionals from Questionnaire 12 months adjusted for age, demands Upper back 1.57 1.09–2.25
Iran 84.5% public hospital (JCQ) disrupted their sex, physical

D. Bernal et al. / International Journal of Nursing Studies 52 (2015) 635–648

n = 545 Nordic daily activities demands
32 years Questionnaire

Herin Prospective cohort Female nurses from Effort-reward Pain or discomfort Multilevel models, 12/14 85.7 Effort-reward Upper limb 9.36 5.86–14.96
et al. (2011) 2006–2008 7 hospitals imbalance (ERI), during the last logistic regression, imbalance Upper limb 1.77 1.31–2.40
France 90% different Nordic 7 days: upper limb adjusted for age, Low support from
department Questionnaire (neck, shoulder, sex, physical managers
n = 2194 elbows, hands, demands
35 years wrist)

Hoe et al. Cross sectional Nurses working in Adaptation of Neck or shoulder Multinomial 10/13 76.9 Low support Neck 1.22 0.64–2.33
(2012) Period not specified three public Karasek model pain lasting for logistic regression, supervisor/co- Shoulder 2.26 1.22–4.16
Australia 38,6% hospitals (CUPID Study more than 1 day adjusted for age, worker Neck 1.51 0.88–2.59
n = 1119 questionnaire) during the previous sex, physical High job strain Shoulder 2.19 1.25–3.83
42 years Nordic month demands Low support
Questionnaire supervisor/co-
worker
High job strain

Mehrdad Cross sectional Nurses Psychosocial Musculoskeletal Logistic regression, 11/13 84.6 Task level category Back 2.86 1.10–7.44
et al. (2010) 2006–2007 n = 317 aspects QPS Nordic complaints or adjusted for age, included questions Neck 0.95 0.37–2.42
Iran 91% 33 years Questionnaire symptoms in past gender related job Shoulder 1.3 0.51–3.30
12 months demands and job Upper limb 1.2 0.36–3.73
control Knee 1.86 0.64–5.34
6.49 2.29–18.37

Sembajwe Cross sectional Health care Job Content Pain in past Binomial, 11/13 84.6 High job demands Multi-site 1.98 1.55–2.53
et al. (2013) October 2009 and workers (staff Questionnaire 3 months (low multinomial, and Low job control Multi-site 0.98 0.76–1.25
USA February 2010 nurse) from two (JCQ) back, shoulder, cumulative logistic Low support Multi-site 1.27 0.43–0.78
79% large hospitals Nordic neck, wrist or regression, co-worker
n = 1572 Questionnaire forearm, adjusted for age,
41 years knee, ankle or feet) sex, occupation
Simon Cross sectional Nurses and aides Effort-reward Pain in relation to Logistic regression, 10/13 76.9 High effort-reward Back 6.2 5.36–7.16
et al. (2008) 2002–2003 n = 16,770 imbalance (ERI), days begin disabled adjusted for age, imbalance/low for
Germany 93% 30 years Copenhagen in the past six country, gender, high disability
Psychosocial months and physical demands
Questionnaire interference with
Scale von Korff daily activities.
grading the
severity of chronic
pain

Smedley Descriptive cohort Nurses Whitehall II study Neck or shoulder Cox regression 11/14 78.6 High demands Neck HR = 0.9 0.7–1.4
et al. (2003) 18 months n = 1239 Nordic pain, for hazard ratios (HRs), Low interest Neck HR = 1.2 0.9–1.8
United 56% 39 years Questionnaire at least one month adjusted for age, Low control Neck HR = 1.1 0.8–1.6
Kingdom at baseline BMI, frequently Low support Neck HR = 0.9 0.6–1.3
feeling tired, low/ Low satisfaction Neck HR = 1.2 0.8–1.8

D. Bernal et al. / International Journal of Nursing Studies 52 (2015) 635–648

tense/under stress,
physical demands

Smith Retrospective Nurses from Karasek model Pain or discomfort Logistic regression, 12/14 85.7 High mental Back 1.14 0.68–1.91
et al. (2004) cohort 5 hospitals in Nordic during the last adjusted for age, pressure Neck 1.79 1.06–3.03
China 12 months different Questionnaire 12 months (neck, department, High mental Shoulder 1.69 0.99–2.89
92% department (Chinese) shoulder, upper physical demands pressure Any site 1.65 0.94–2.89
n = 282 back or lower back) High mental Back 1.97 1.16–3.35
34 years pressure Neck 2.52 1.09–6.23
High mental Shoulder 2.00 0.90–4.59
pressure Any site 3.16 1.02–13.87
Low support
Low support
Low support
Low support

Smith Cross sectional Nurses Karasek model Symptoms at Logistic regression 11/13 84.6 High mental Back 1.94 1.32–2.86
et al. (2006) 12 months n = 844 Nordic certain body sites (Mantel Haenszel pressure Neck 1.53 1.02–2.31
Japan 72% 32 years Questionnaire over the previous method) adjusted High mental Shoulder 2.07 1.35–3.17
(Chinese) 12 month period for age, physical pressure Any site 1.42 0.83–2.38
demands High mental Back 1.16 0.77–1.74
pressure Neck 1.07 0.71–1.60
High mental Shoulder 0.68 0.44–1.06
pressure Any site 0.68 0.39–1.24
Low support
Low support
Low support
Low support

Sorour and Cross sectional Nurses in the Job Content Pain and Pearson correlation 10/13 76.9 Job demands Number of B = 0.077 0.14–0.02
El-Maksoud October–December emergency Questionnaire discomfort, for the and multiple linear painful
(2012) 2010 department of (JCQ) past 12 months and stepwise anatomical
Egypt Response rate not public hospitals Nordic past 7 days in each regression. sites
specified n = 58 Questionnaire of body areas Variables excluded
28 years by model: sex, age,
BMI, work duration

641
Table 1 (Continued )

642
Study ID, Design, Follow-up Study participants, Measure Outcome Analysis, Quality % Exposure Anatomic OR 95% CI
Country period, Response Sample size, (psychosocial measured Adjustment score (QS) variables site
rate Mean age factors and MSD) variables

Stone et al. Cross sectional Nurses Perceived nursing Injury back, Multivariate 11/13 84.6 Low opportunity Any site 1.64 1.26–2.12
(2007) 2004 n = 1551 work environment shoulder, neck, hip models for each for advancement Any site 1.37 1.05–1.80
USA 50% 44 years of critical care or leg in the last outcome, adjusted Low unit decision
nurses (PNWE). Ad 4 months for demographic, making
hoc questionnaire employment
characteristics

Surawera Cross sectional Nurses working at Karasek model Wrist or hand pain Logistic regression, 11/13 84.6 High job strain Wrist or 1.56 1.03–2.37
et al. (2012) October 2009 and three hospitals Nordic in the past month adjusted for age, Job insecurity hand Wrist 1.55 1.04–2.28
Australia January 2010 n = 1111 Questionnaire sex, physical or hand

D. Bernal et al. / International Journal of Nursing Studies 52 (2015) 635–648

39% 42 years demands

Violante Cross sectional Nurses and aides Karasek model Back disorders Multinomial 10/13 76.9 Work Acute low 1.19 0.89–1.59
et al. (2004) September 1997 from university Ad hoc acute and chronic logistic regression, environment/Job back pain 1.11 0.82–1.50
Italy 95.2% hospital questionnaire for adjusted for age, satisfaction: Chronic 1.15 0.86–1.53
n = 901 musculoskeletal body mass index Having to do many low back 1.32 0.98–1.79
35 years disorders (BMI), motherhood, things hurriedly at pain
smoking, scoliosis, the same time
trauma/fractures of Gratification from
spine, pelvis and/or responsibility
legs, other
diagnosed spine
pathologies, sport
scores

Warming Cross sectional Internal medicine Logbook Low back, neck, Logistic regression, 10/13 76.9 Time pressure Back 1.17 0.27–5.01
et al. (2009) 12 months and surgery wards instrument shoulder and knee adjusted for (how has the time Neck 1.16 0.24–5.54
Denmark 92% nurses (Gonge 2001) pain at data gender, age, time pressure been Knee 0.68 0.06–7.27
n = 148 collection data collection, today at work)
33 years physical demands

Weyers Cross sectional Nurses and aides Effort-reward Musculoskeletal Multivariate 11/13 84.6 Effort-reward Any site 4.76 2.38–9.52
et al. (2006) 1999 living in the county imbalance (ERI) complaints logistic regression imbalance
Denmark 67.7% of North Jutland questionnaire anywhere on the adjusted for age,
n = 367 (Danish) body smoking, alcohol
41 years Ad hoc questions consumption,
on musculoskeletal physical activity,
complaints occupational status

Yip (2002) Prospective cohort Nurses Scale 3 of MMPI New low back pain Logistic regression 11/14 78.6 Relationship with Back 1.85 1.00–3.42
China 12 months n = 236 Aberdeen’s LBP in past 12 months model, adjusted for colleagues
81% 31 years Scale after baseline physical demands
interview of work,
demographic,
lifestyle factors
 D. Bernal et al. / International Journal of Nursing Studies 52 (2015) 635–648 643

Table 2
Work-related psychosocial risk factors and musculoskeletal disorders. Pooled estimates and heterogeneity values for each subset of studies according to
study design.

Subgroup Studies (n) Overall effect Heterogeneity Studies ID

test

OR 95% CI I2 P-value

Cross sectional studies

Demand-control/Back
Demand-control/Neck
Demand-control/Shoulder
Demand-control/Knee
Demand-control/any site
Low social support/Any site
Effort reward imbalance/Any site
8 1.56 1.22–1.99 75.3 <0.001 Choobineh et al. (2010), Bos et al. (2007), De
Souza Magnago et al. (2010), Mehrdad et al. (2010),
Smith et al. (2006), Stone et al. (2007), Alexopoulos
et al. (2003), Golabadi et al. (2013).
7 1.34 1.02–1.78 59.9 0.02 Bos et al. (2007), De Souza Magnago et al. (2010),
Mehrdad et al. (2010), Smith et al. (2006),
Alexopoulos et al. (2003), Warming et al. (2009),
Hoe et al. (2012).
6 1.89 1.53–2.34 0 0.93 Choobineh et al. (2010), De Souza Magnago et al.
(2010), Mehrdad et al. (2010), Smith et al. (2006),
Alexopoulos et al. (2003), Hoe et al. (2012).
3 2.21 1.07–4.54 43.1 0.17 Mehrdad et al. (2010), Alexopoulos et al. (2011),
Warming et al. (2009).
3 1.38 1.09–1.75 0 0.91 Smith et al. (2006), Stone et al. (2007), Sembajwe
et al. (2013).
5 1.20 0.91–1.59 70.7 0.01 Bos et al. (2007), Smith et al. (2006), Alexopoulos et
al. (2003, 2011), Sembajwe et al. (2013).
2 6.13 5.32–7.07 0 0.47 Simon et al. (2008), Weyers et al. (2006).

Cohort studies
Demand-control/Back 3 1.52 1.14–2.01 0 0.42 Alexopoulos et al. (2006), Yip (2002), Smith et al.
(2004)
Low social support/Back 3 1.82 1.43–2.32 0 0.94 Alexopoulos et al. (2006), Yip (2002), Smith et al.
(2004)

I2 = 0%: no heterogeneity; I2 = around 25%: low heterogeneity; I2 = around 50%: moderate heterogeneity; I2 = around 75%: high heterogeneity.

et al., 2004; Warming et al., 2009; Weyers et al., 2006) and
6 were prospective cohort studies (Alexopoulos et al.,
2006; Camerino et al., 2001; Herin et al., 2011; Smedley
et al., 2003; Smith et al., 2004; Yip, 2002).
Most studies (n = 11) were conducted in European
countries, those that were not, came from Iran (3),
Australia (2), China (2), Brazil (1), Egypt (1), United States
(1), and Brazil and Italy (1). The number of participants in
the included studies ranged from 58 to 16,670, and most of
them were women (90%), with an overall mean age that
ranged between 27 and 44 years-old. Sixteen studies
focused on nurses, and 8 studies recruited both nurses and
aides. Different instruments were used to assess MSD and
psychosocial risk factors. Most studies (70%) used the

Study Year OR (95% CI)

Alexopoulos 2003 1.50 (0.92, 2.45)

Smith 2006 1.94 (1.32, 2.86)

Bos 2007 1.09 (1.08, 1.14)

Stone 2007 1.37 (1.05, 1.80)

Choobineh 2009 2.25 (1.26, 4.01)

Magnago 2010 1.36 (0.72, 2.60)

Mehrdad 2010 2.86 (1.10, 7.44)

Golabadi 2013 1.73 (1.18, 2.53)

Fixed (I-squared = 75.3%, p = 0.000) 1.10 (1.07, 1.13)

Randon 1.56 (1.22, 1.99)

.1 1 10

Fig. 2. High demands–low control and low back pain in cross sectional studies.
644 D. Bernal et al. / International Journal of Nursing Studies 52 (2015) 635–648
Standardized Nordic Questionnaire to measure MSD.
Psychosocial risk factors were measured by the Karasek
Job Content (JCQ) questionnaire, or an adapted version
(Camerino et al., 2001; Carugno et al., 2012; Hoe et al.,
2012), the Effort Reward Imbalance (ERI) questionnaire
and the Copenhagen Psychosocial Questionnaire (COP-
SOQ). Furthermore, 13 studies were classed as ‘‘high
quality’’ (with a score above 80% of the maximum possible
score), and 11 were considered as ‘‘intermediate quality’’
as their score ranged between 76.9% and 78.6%.
3.2. Meta-analysis
Pooled risk estimates and heterogeneity values for each
subset of studies are summarized in Table 2. Statistically
significant associations were found for high demands/low
job control with the prevalence of low back pain (OR 1.56;
95% CI 1.22–1.99) and the incidence of low back pain (OR
1.52; 95% CI 1.14–2.01). Exposure to high demands/low job
control was also associated with the prevalence of
shoulder pain (OR 1.89; 95% CI 1.53–2.34), knee pain
(OR 2.21; 95% CI 1.07–4.54) and pain at any anatomical site
(OR 1.38; 95% CI 1.09–1.75), respectively. Likewise, low
social support was significantly associated with the
incidence of back pain (OR 1.82; 95% CI 1.43–2.32), and
a strong association was observed between effort-reward
imbalance and the prevalence of pain at any anatomical
site (OR 6.13; 95% CI 5.32–7.07). In two cross-sectional
subsets of meta-analysis heterogeneity was classed as
moderate, and in one subset of cross-sectional studies
heterogeneity was considered high (Table 2). Due to the
maximum number of tables and figures allowed, only
forest plots of 3 subsets of cross-sectional studies (Figs. 2–
4) and 1 subset of cohort studies (Fig. 5) were included in
the manuscript.
Study Year
Alexopoulos 2003
Smith 2006
Choobineh 2009
Magnago 2010
Mehrdad 2010
Hoe 2011
Fixed (I-squared = 0.0%, p = 0.937)
Randon
.1
Fig. 3. High demands–low control and shoulder pain in cross sectional studies.
3.3. Meta-regression
The three subsets of studies where heterogeneity was
high (i. high psychosocial demands/low job control with
the prevalence of low back pain) or moderate (ii. high
psychosocial demands/low job control with the prevalence
of neck pain; and iii. low social support with the prevalence
of pain at any anatomical site) were considered for meta-
regression. Only the variable ‘‘sample size’’ partially
explained the high and moderate heterogeneity found in
subsets (i) and (ii) (data not shown).
4. Discussion
According to our findings, work-related psychosocial
factors seem to be associated with MSD in hospital nurses
and nursing aides. Specifically, exposure to high demands/
low control, effort-reward imbalance and low social
support were found to be associated with low back, neck,
shoulder, upper extremity, knee, and/or pain at any
anatomical site, either in nurses, aides or both.
To our knowledge this is the first meta-analysis that
explores the association between the exposure to psycho-
social factors in the workplace and MSD in nurses and
nursing aides who work in hospitals. All included studies
used validated instruments to assess the exposure of
psychosocial risk factors at work, based on well-established
models among the scientific community, which have been
widely used in previous studies. In addition, to assess MSD,
most of the studies used the validated and widely used
Nordic questionnaire (Kuorinka et al., 1987). It might be
argued that self-reporting of workers’ perception could be a
source of bias. However, self-rated health is considered a
good indicator of health status (Kaplan et al., 1996; Palmer
et al., 2008). The quality assessment of the included studies
was based on validated scales previously used in other
published systematic reviews (Alexopoulos et al., 2006;
Bongers et al., 2002; Yip, 2002).
OR (95% CI)
1.84 (1.21, 2.82)
2.07 (1.35, 3.17)
1.70 (1.04, 2.73)
1.97 (1.07, 3.64)
1.30 (0.51, 3.30)
2.19 (1.25, 3.83)
1.89 (1.53, 2.34)
1.89 (1.53, 2.34)
1 10
 D. Bernal et al. / International Journal of Nursing Studies 52 (2015) 635–648 645

Study Year OR (95% CI)

Alexopoulos 2003 1.93 (1.24, 2.99)

Smith 2006 1.58 (1.02, 2.51)

Bos 2007 1.01 (0.97, 1.06)

Warming 2009 1.16 (0.24, 5.54)

Magnago 2010 1.43 (0.75, 2.73)

Mehrdad 2010 0.95 (0.37, 2.42)

Hoe 2011 1.51 (0.88, 2.59)

Fixed (I-squared = 59.9%, p = 0.021) 1.03 (0.98, 1.07)

Randon 1.34 (1.02, 1.78)

.1 1 10

Fig. 4. High demands–low control and neck pain in cross sectional studies.

Against these strengths, some limitations need to be
addressed. Most of the included studies in our meta-analysis
were cross-sectional and therefore, reverse causality cannot
be ruled out. Another important limitation is that we used
random effects models, assuming that the included studies
were representative of the hypothetical population of
studies, and that heterogeneity among the studies may be
represented by a single variance granting too much weight
to studies with small sample size. Likewise, it is possible that
studies without positive or statistically significant findings

Year

Study publication OR (95% CI)

Yip 2002 1.85 (1.00, 3.42)

Smith 2004 1.14 (0.68, 1.91)

Alexopoulos 2006 1.66 (1.10, 2.50)

Fixed (I-squared = 0.0%, p = 0.415) 1.52 (1.14, 2.01)

Random
1.52 (1.14, 2.01)

.1 1 10

Fig. 5. High demands–low control and back pain in cohort studies.

646 D. Bernal et al. / International Journal of Nursing Studies 52 (2015) 635–648
may be less likely to be published by journals. For each
subset of meta-analysis we assessed the possibility of
publication bias by using Begg’s test (Palma and Delgado,
2006). However, the potential risk of publication bias was
quite low (data not shown). Furthermore, our systematic
review and meta-analysis included predominantly nurses.
Thus, it is possible that findings, such as the association
between job control and musculoskeletal pain, would have
been different in a population largely consisting of nursing
aides. Finally, the Standardized Quality Scale used to
evaluate the quality assessment of the identified studies
does not include the assessment of bias. This is a systematic
review of observational studies about psychological risk
factors at work; therefore, the possibility of selection bias
cannot be dismissed.
The prevalence of low back pain in hospital nurses and
nursing aides is very high, and it is the leading cause of
sickness absence in this occupational group (Maul et al.,
2003). Low back pain has been a subject of extensive
research and is traditionally attributed to high physical
demands (Harcombe et al., 2010; Menzel, 2004). However,
the benefits from interventions (training or mechanical
aides) to reduce physical demands and prevent low back
pain have been small and of uncertain cost-effectiveness
(Verbeek et al., 2011). A systematic review suggested that
other underlying occupational and individual risk factors
may contribute to the occurrence of low back pain in
workers exposed to heavy manual handling (Punnett and
Wegman, 2004). Among other potential occupational risks,
work-related psychosocial factors, such as high job
demand, low job control, low social support and effort-
reward imbalance might have a role in the prevalence and
incidence of low back pain in nurses and nursing aides. A
systematic and critical review of cohort studies performed
by Hartvigsen et al., did not find an association between
work organizational factors (such as social support) and
low back pain (Hartvigsen et al., 2004). These findings are
contrary to what we found in our systematic review.
However, the Hartvigsen review included a wide variety of
occupations, and used an evidence synthesis instead of
meta-analysis. Likewise, it is possible that due to the
subjective nature of musculoskeletal symptoms, the
definition of outcomes varied among studies. Also, the
definition of psychosocial factors and the way these
variables were collected varies. Therefore, it is possible
that differences in the ‘‘case definition’’ might explain, at
least partially, the lack of comparability and the contra-
dictory findings between both reviews. Despite the small
number of cohort studies included in our meta-analysis,
they provided consistent evidence of an association
between exposure to work-related psychosocial risk
factors and MSD in hospital nurses and nursing aides.
Some mechanisms might explain this. Ando et al.
proposed that workers exposed to high time pressure to
meet demands at work, lack of social support and other
organizational deficiencies, could increase the number of
repetitive movements and also be predisposed to un-
healthy awkward postures at work (Ando et al., 2000).
Moreover, exposure to high time pressure could also
increase workers’ mechanical work-load, which can
produce muscular strain. This, in turn, may generate pain
or exacerbate pre-existing pain (Ando et al., 2000). Due to
the strong relationship between physical demands at work
and MSD, it has been suggested that physical demands at
work must be taken into account when analysing the
relationship between work-related psychosocial risk
factors and MSD (MacDonald et al., 2001). In fact, most
of the studies included in our meta-analysis considered
physical demands in their analysis as a confounding factor.
Only three did not incorporate physical demands as a
confounder (Mehrdad et al., 2010; Sembajwe et al., 2013;
Stone et al., 2007). We conducted the meta-analysis with
and without these three studies, and findings did not
change significantly. Our meta-analysis results suggest a
strong association between work-related psychosocial risk
factors and the occurrence of MSD, even after adjustment
for exposure to physical demands.
In conclusion, our results provide consistent evidence of
an association between exposure to work-related psycho-
social risk factors and MSD in hospital nurses and aides.
Nevertheless, future studies should use longitudinal
designs to undertake more accurate assessments of
exposure to work-related psychosocial risk factors that
might have a strong impact on workers’ health. Finally,
interventions are needed to evaluate the effectiveness of
preventive strategies to reduce the occurrence of MSD in
hospital nurses and nursing aides. These interventions
should take into account not only ergonomics, but also the
improvement of organizational aspects of the work
environment.
Conflict of interest. None declared.
Funding. This study has been funded by the fellowship
project Erasmus – Eracol, University of Panama and the
Center for Research in Occupational Health (CiSAL), Univer-
sitat Pompeu Fabra (Barcelona, Spain).
Ethical approval. Not required.
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