581933 HFSXXX10.
1177/0018720815581933Human FactorsMSD Pain in Nursing Workers
Prevalence of Musculoskeletal Disorders for
Nurses in Hospitals, Long-Term Care Facilities, and
Home Health Care: A Comprehensive Review
Kermit G. Davis and Susan E. Kotowski, University of Cincinnati, Cincinnati, Ohio
Objective: The aim of this study was to determine
the prevalence of musculoskeletal pain and reported
injuries for nurses and nursing aides.
Background: Nurses and nursing aides suffer
from work-related pain and musculoskeletal disorders
(MSDs). Although there have been a plethora of stud-
ies on MSDs, an overall understanding of the prevalence
of MSDs and pain can lead to better prioritization of
research needs with respect to the health care industry.
Method: A total of 132 articles on prevalence of
MSD pain and injuries were included in the review.
All articles were published in peer-reviewed English-
speaking journals and subjected to a quality review.
Results: Reported prevalence of MSD pain for nurses
and nursing aides was highest in the low back, followed by
shoulders and neck. However, the majority of the stud-
ies have been concentrated on 12-month pain in the low
back and predominantly in hospitals. Few researchers
have investigated pain in the upper and lower extremi-
ties (less than 27% of the studies). Even fewer researchers
have evaluated reported injuries or even subjective lost-
time injuries (less than 15% of the studies).
Conclusion: MSD pain in the nursing profession has
been widely investigated worldwide, with a major focus
on low-back pain. Given new directions in health care,
such as patients who live longer with more chronic dis-
eases, bariatric patients, early mobility requirements, and
those who want to be at home during sickness, higher
prevalence levels may shift to different populations—
home health care workers, long-term care workers,
and physical therapists—as well as shift to different body
regions, such as shoulders and upper extremities.
Keywords: spine, low back, biomechanics, anthro-
pometry, work physiology, wrist, upper extremity,
musculoskeletal system (musculoskeletal disorders,
cumulative trauma disorder), nursing and nursing sys-
tems, health care/health systems
Address correspondence to Kermit G. Davis, University of
Cincinnati, Low Back Biomechanics and Workplace Stress
Laboratory, 160 Panzeca Way, Kettering Lab, Cincinnati, OH
45267-0056, USA; e-mail: Kermit.davis@uc.edu.
HUMAN FACTORS
Vol. 57, No. 5, August 2015, pp. 754­–792
DOI: 10.1177/0018720815581933
Copyright © 2015, Human Factors and Ergonomics Society.
Introduction
Musculoskeletal disorders (MSDs) plague the
nursing profession (nurses and nursing aides).
National injury costs in the United States for
nurses and nursing aides (in 2013 U.S. dollars)
have been estimated to be $1.6 billion, $344
million, $192 million, $65 million, and $134
million for low back, shoulder, knee, neck, and
hand/wrist, respectively (Waehrer, Leigh, &
Miller, 2005). The average MSD claim costs
have been reported between $6,190 to $93,225
(Alamgir et al., 2008; Badii, Keen, & Yassi,
2006; Haglund, Kyle, & Finkelstein, 2010),
and average low-back claim costs ranged from
$2,270 to $14,235 (Black, Shah, Busch, Met-
calfe, & Lim, 2011; Charney, Simmons, Lary,
& Metz, 2006; Cohen-Mansfield, Culpepper, &
Carter, 2006; Goldman, Jarrard, Kim, Loomis,
& Atkins, 2000; Lipscomb, Schoenfisch, Myers,
Pompeii, & Dement, 2012; Meyer & Muntaner,
1999; Park, Bushnell, Bailer, Collins, & Stayner,
2009; Stichler, Feiler, & Chase, 2012). Based on
these cost figures, MSDs have placed a signifi-
cant burden on the health care sector and specifi-
cally on the health care workers.
Understanding how MSDs impact workers,
specifically nurses and nursing aides in this case,
requires quantification of the prevalence of pain,
reports of injuries and disability, and the under-
standing of the potential risk factors for these
health outcomes. Ferguson and Marras (1997)
developed a model for the progression of low-
back disorders that can be the foundation for the
progression of MSDs. The progression from
stressor to disability has the following stages: (1)
discomfort, (2) symptoms, (3) disorder (injury or
illness), (4) incidence, (5) restricted days, (6) lost
days, and (7) disability. In the current review, we
utilized this progression to evaluate the different
MSD outcomes for health care professionals. Fur-
ther, the current review focused on the health out-
comes and not the risk factors associated with
MSD Pain in Nursing Workers
MSD outcomes. Other researchers have con-
ducted reviews of the studies investigating the risk
factors (Bakker, Verhagen, van Trijffel, Lucas, &
Koes, 2009; Buckle, 1987; Kuiper et al., 1999;
Nelson & Baptiste, 2006). The authors of these
reviews have identified patient-handling tasks to
be associated with MSDs, specifically in the low
back.
The objectives of the current review were to
(a) determine the overall prevalence of MSD
outcomes for nurses and nursing aides; (b) deter-
mine whether prevalence of MSDs vary by body
region, occupational classification, and health
care facility; and (c) identify the limitations of
the understanding of MSD prevalence (e.g.,
where are the gaps). Based on the review, priori-
ties will be identified to fill the gaps and lead to
a better understanding of pain and suffering
that nurses and nursing aides experience world-
wide, specifically identifying body regions, out-
comes (e.g., lifetime, yearly, monthly, current),
and facilities that need to have more research
initiated.
Method
A comprehensive literature review was con-
ducted to identify all published articles on the
reported prevalence of MSDs in nurses and
nursing aides. The review followed the critical
procedures of Pluye and Hong (2014) and the
Mixed Methods Appraisal Tool (MMAT). Each
article was rated based on the criteria for quali-
tative and quantitative random designs, quanti-
tative nonrandom designs, and mixed methods
(Pluye et al., 2011). Any article that was scored
less than 25% on quality was eliminated from
the analyses but reported in the summary table.
Although the majority of the studies concen-
trated on the prevalence of MSDs in nurses and
nursing aides, there were several studies that
included general health care professionals as the
subject population without differentiating exact
professional discipline.
Search Methods
A search for articles was completed over a
2-year period (September 2012 to September
2014), utilizing two search engines: Google
Scholar and Thomson Reuters Web of Knowl-
edge, which includes Medline, BIOSIS, Data
755
Citation Index, Inspec, and Web of Science
Core Collections. Combinations of words were
entered into both search engines. The search
words utilized in the search included nurses,
nursing, nursing aides, long-term care facilities,
hospitals, home healthcare, musculoskeletal
disorders, low back, hand, wrist, knee, shoulder,
neck, discomfort, injuries, and pain.
Inclusion/Exclusion Criteria
The following four inclusion criteria were
used to select the articles to be included into
this review: (a) full article study investigating
the prevalence of pain or MSD injury in one of
the targeted body regions for nurses and nurs-
ing aides, which included the following clas-
sifications: nurses, nursing aides, clinical nurse,
assistant nurse, health care assistant, home care
aide, practical nurse, and professional nurse;
(b) published as a full-text article in an English-
language peer-reviewed journal; (c) focus on
health care setting, including hospitals, long-
term care facilities, and home health care; (d)
published prior to September 1, 2014. No exclu-
sion criteria were based upon quality of the
assessment, country of origin, or study design.
Results
In all, a total of 132 articles were included
in the review. Table 1 provides a summary of
the studies, including study population, study
design, type of MSD outcome (e.g., pain assess-
ment in lifetime, previous 12 months, previous
3 to 6 months, and current), reported MSD
injuries (using company injury or compensation
records), and lost-time injuries (subjectively
reported) as well as the body region of pain/
injury (e.g., low back, shoulder, neck, upper
extremity, and lower extremity). Overall, most
of the research into MSD pain and injuries for
nurses and nursing aides utilized subjective
surveys to take a snapshot of the health status
(78%). A prospective design was utilized in
only 19% of the studies, with 88% of these
prospective studies utilizing a survey to assess
MSD pain and injuries. Authors of four stud-
ies investigated previous injuries utilizing a
retrospective design. Only two studies utilized
a clinical evaluation to determine the pres-
ence of pain or injury. The majority of study
(text continues on p. 778)
 Table 1: Summary of the Studies Included in Review, Including Study Population, Study Design, MMAT Criteria, Type of Pain and Injury Outcome, and Body
Region

756
Reporting Period and Type Body Region

MMAT Life- 12- Cur- 3–6 Lost Upper Lower

Author Study Population Study Design Criteriaa time Mon rent Months MSD Days Back Shoulder Neck Extremity Extremity

Ahmadi, Rezaiee, 348 nurses in two Cross-sectional QUAN-NR X X

& Hashemian hospitals in Iran study with 75%
(2014) survey
Alamgir et al. 8,636 nurses in 1-year QUAN-NR X
(2008) hospitals and prospective 75%
long-term care study
facilities in
Canada
Alexopoulos, 129 nurses and Cross-sectional QUAN-NR X X X X
Burdorf, & 264 caregivers study with 100%
Kalokerinou, in hospitals in survey for
(2003, 2006) the Netherlands Netherlands
and 351 nurses (1998–1999)
in hospitals in and Greece
Greece (2001–2002)
Alexopoulos 448 nurses in 6 Cross-sectional QUAN-NR X X X X
et al. (2011) hospitals in study with 100%
Greece survey
Alperovitch- 57 nurses from Cross-sectional QUAN-NR X X X
Najenson, hospital and study with 75%
Sheffer, Treger, 54 nurses from survey
Finkels, & home health in
Kalichman (2014) Israel
Anap, Iyer, & Rao 212 nurses in Cross-sectional QUAN-D X X X X X X
(2013) unknown study with 75%
number of survey
hospitals in India
(continued)
 Table 1: (continued)

Reporting Period and Type Body Region

MMAT Life- 12- Cur- 3–6 Lost Upper Lower

Author Study Population Study Design Criteriaa time Mon rent Months MSD Days Back Shoulder Neck Extremity Extremity

Andersen et al. 5,017 health Cross-sectional QUAN-NR X X X

(2014) care workers in study with 75%
nursing homes survey
in Denmark
Ando et al. (2000) 314 full-time RNs Cross-sectional QUAN-NR X X X X X
in hospitals in study with 75%
Japan survey
Arad & Ryan 831 nurses in Cross-sectional QUAN-NR X X X
(1986) a hospital in study with 75%
Australia survey
Attar (2014) 200 RNs in a Cross-sectional QUAN-NR X X X X X X
hospital in Saudi study with 100%
Arabia survey
Attarchi, Raeisi, 454 nurses Cross-sectional QUAN-NR X X X X X X
Namvar, & and NAs in a study with 100%
Golabadi (2014) hospital in Iran survey
Beija et al. (2005) 193 nurses and Cross-sectional QUAN-NR X X X X
157 other study with 75%
workers in survey
hospital in
Tunisia
Botha & Bridger 100 nurses from 3 Cross-sectional QUAN-DE X X X X X X
(1998) private hospitals study with 100%
in South Africa survey
and direct
observation
Brulin et al. (1998) 361 home health Cross-sectional QUAN-NR X X X X X X
care workers in study with 100%

757
Sweden survey
(continued)
 Table 1: (continued)

758
Reporting Period and Type Body Region

MMAT Life- 12- Cur- 3–6 Lost Upper Lower

Author Study Population Study Design Criteriaa time Mon rent Months MSD Days Back Shoulder Neck Extremity Extremity

Burton et al. 1,783 nurses from Cross-sectional QUAN-NR X X X X

(1997) hospitals in study with 100%
Belgium booklet of
surveys
Byrns, Reeder, Jin, 136 RNs in the Cross-sectional QUAN-NR X X
& Pachis (2004) hospitals in study with 75%
United States survey
Callison & 104 RNs, 11 LPNs/Cross-sectional QUAN-DE X X X X X
Nussbaum, LVNs, and 27 study with 50%
(2012) NAs in hospital survey
in United States and direct
observation
Cameron, 303 RNs in Cross-sectional QUAN-NR X X X X X
Armstrong- hospitals in survey and 100%
Stassen, Kane, & United States interview
Moro (2008)
Cheung (2010) 388 nursing 2-year QUAN-DE X X
students in prospective 75%
Hong Kong study with
survey
Cheung, Gillen, 491 home Cross-sectional QUAN-NR X X X X X X
Faucett, & care nursing study with 100%
Krause (2006) personnel in survey
hospital in Hong
Kong

(continued)
 Table 1: (continued)

Reporting Period and Type Body Region

MMAT Life- 12- Cur- 3–6 Lost Upper Lower

Author Study Population Study Design Criteriaa time Mon rent Months MSD Days Back Shoulder Neck Extremity Extremity

Choobineh, 375 nurses in Cross-sectional QUAN-NR X X X X X X

Movahed, hospital in Iran study with 100%
Tabatabaie, survey
& Kumashiro
(2010)
Chiou, Wong, & 3,159 nursing Cross-sectional QUAN-NR X X X X X
Lee (1994) personnel in study with 100%
large medical survey
center in China
Cunningham, 246 health care Cross-sectional QUAN-NR X X X X
Flynn, & Blake personnel in study with 75%
(2006) hospital in survey
Ireland
Cust, Pearson, & 413 RNs and Cross-sectional QUAN-DE X X
Mair (1972) 343 NAs in study with 75%
1 hospital in survey
Scotland
Daraiseh et al. 34 RNs in 2 Cross-sectional QUAN-DE X X X X X X
(2003) hospitals in study with 50%
United States survey
D’Arcy, Sasai, & 2,692 NAs in Cross-sectional QUAN-NR X X
Stearns (2012) 582 long-term study with 100%
facilities in national survey
United States
Daws (1981) 2,000 NAs in 2-year QUAN-NR X X
1 hospital in prospective 25%
United Kingdom study using
survey

759
(continued)
 Table 1: (continued)

760
Reporting Period and Type Body Region

MMAT Life- 12- Cur- 3–6 Lost Upper Lower

Author Study Population Study Design Criteriaa time Mon rent Months MSD Days Back Shoulder Neck Extremity Extremity

de Castro, 655 nurses Cross-sectional QUAN-DE X X

Cabrera, Gee, attending study with 100%
Fujishiro, & conference in survey at
Tagalog (2009) Philippines national
conference
Dehlin, Hedenrud, 267 NAs in Cross-sectional QUAN-DE X X
& Horal (1976) hospital in study with 100%
Sweden interviews
Dehlin & 50 nurses and 39 Cross-sectional QUAN-DE X X X X
Jaderberg NAs in hospital study with 25%
(1982) in Sweden survey
with direct
observation
Dulon, Kromark, 1,390 nurses and Cross-sectional QUAN-NR X X X X X X
Skudlik, & NAs in 68 long- study with 100%
Nienhaus (2008) term facilities in survey and
Germany clinical
examination
Dundara, 148 nurses in Cross-sectional QUAN-NR X X X
Ozmenb, Ilgunc, hospital in study with 100%
Cakmakcid, & Turkey survey
Alkise (2010)
Elert, Brulin, 97 home health Cross-sectional QUAN-NR X X X X
Gerdle, & care personnel observation 100%
Johansson in Sweden and
(1992) quantification

(continued)
 Table 1: (continued)

Reporting Period and Type Body Region

MMAT Life- 12- Cur- 3–6 Lost Upper Lower

Author Study Population Study Design Criteriaa time Mon rent Months MSD Days Back Shoulder Neck Extremity Extremity

El-Sayyad, 116 nurse and Cross-sectional QUAN-NR X X

Naushad, 70 other health study with 75%
Mathew, & care workers in survey
Kumar (2013) 2 hospitals in
Iran
Engels, van der 846 nurses in Cross-sectional QUAN-NR X X X X X X
Gulden, Senden, 4 long-term study with 100%
& van der Hof facilities in the survey
(1996) Netherlands
Eriksen (2003) 6,485 NAs in Cross-sectional QUAN-DE X X X X X X
long-term study with 100%
facilities, survey
hospitals,
and homes in
Norway
Erikson, 4,266 NAs in 15-month QUAN-NR X X
Bruusgaard, & long-term prospective 100%
Knardahl (2004) facilities, study with
hospitals, surveys
and homes in
Norway
Estryn-Beharl et 1,505 health care Cross-sectional QUAN-NR X X X X
al. (1990) workers in 26 study with 75%
departments survey
in hospitals in
France
Fabunmi, Oworu, 214 nurses in Cross-sectional QUAN-DE X X X X X X
& Odunaiya 1 hospital in study with 100%
(2008) Nigeria survey

761
(continued)
 Table 1: (continued)

762
Reporting Period and Type Body Region

MMAT Life- 12- Cur- 3–6 Lost Upper Lower

Author Study Population Study Design Criteriaa time Mon rent Months MSD Days Back Shoulder Neck Extremity Extremity

Fanello, Jousset, 272 health care 2-year QUAN-NR X X

Roquelaure, staff in hospital prospective 100%
Chotard- in France study with
Frampas, & surveys
Delbos (2002)
Feldstein, Valanis, 40 RNs, 7 NAs, 1-month QUAN-NR X X X
Vollmer, and 8 orderlies prospective 100%
Stevens, & in 2 hospitals study using
Overton (1993) in the United survey and
States physical
assessment
Felknor, Aday, 854 health care Cross-sectional QUAN-NR X X X
Burau, Delclos, workers in 10 study with 100%
& Kapadia hospitals in survey
(2000) Costa Rica
Feng, Chen, & 204 NAs in 31 Cross-sectional QUAN-NR X X X
Mao (2007) long-term study with 100%
facilities in survey
Taiwan
Fochsen, 440 RNs and 655 Cross-sectional QUAN-NR X X X X X X
Josephson, NAs in hospital study with 75%
Hagberg, in Sweden survey
Toomingas,
& Lagerstrom
(2006)
French, Flora, 60 nurses in Cross-sectional QUAN-DE X X
Ping, Bo, & Rita hospital in Hong study with 50%
(1997) Kong survey
(continued)
 Table 1: (continued)

Reporting Period and Type Body Region

MMAT Life- 12- Cur- 3–6 Lost Upper Lower

Author Study Population Study Design Criteriaa time Mon rent Months MSD Days Back Shoulder Neck Extremity Extremity

Garg & Owen 38 NAs in nursing 8-month QUAN-NR X X X X

(1992) home in United prospective 100%
States study using
survey and
observation
Garg, Owen, & 38 NAs in nursing Cross-sectional QUAN-NR X X
Carlson (1992) home in United study with 75%
States survey
Genevay et al. 167 NAs, 233 Cross-sectional QUAN-NR X X X
(2011) RNs, and study with 75%
809 other survey
health care
professionals
in unknown
number of
hospitals in
Switzerland
Gerdle, Brulin, 97 health care Cross-sectional QUAN-NR X X X X X X
Elert, & providers study with 100%
Granlund (1994) in homes in survey
Sweden
Ghilan et al. 687 nurses Cross-sectional QUAN-NR X X X X X
(2013) in multiple study with 100%
hospitals in survey
Yemen
Gimeno, Felknor, 475 health care Cross-sectional QUAN-NR X X
Burau, & Delclos workers in 10 study with 50%
(2005) hospitals in survey
Costa Rica

763
(continued)
 Table 1: (continued)

764
Reporting Period and Type Body Region

MMAT Life- 12- Cur- 3–6 Lost Upper Lower

Author Study Population Study Design Criteriaa time Mon rent Months MSD Days Back Shoulder Neck Extremity Extremity

Green (1996) 10 health care Cross-sectional MM X X

workers in study with 66%
hospital in direct
United Kingdom observation
and structured
interview
Guo et al. (1995) Unknown number Cross-sectional QUAN-NR X X
of caregivers study with 75%
in long-term annual survey
facilities, of national
hospitals in health
United States
Guo, Tanaka, Unknown number Cross-sectional QUAN-NR X X
Halperin, & of caregivers study with 75%
Cameron (1999) in long-term annual survey
facilities, of national
hospitals in health
United States
Harber et al. 550 nursing Cross-sectional QUAN-NR X X X
(1985) personnel in study with 50%
hospital in survey
United States
Harcombe, 181 nurses in Cross-sectional QUAN-NR X X X X X X
McBride, unknown study with 75%
Derrett, & Gray number of survey
(2009) hospitals, home
health, long-term
care, and other
facilities in New
Zealand
(continued)
 Table 1: (continued)

Reporting Period and Type Body Region

MMAT Life- 12- Cur- 3–6 Lost Upper Lower

Author Study Population Study Design Criteriaa time Mon rent Months MSD Days Back Shoulder Neck Extremity Extremity

Hartvigsen, 345 nurses and 2-year QUAN-NR X X

Lauritzen, Lings, NAs in homes in prospective 100%
& Lauritzen Denmark study with
(2005) survey
Hofmann, Stossel, 2,176 nurses Cross-sectional QUAN-NR X X X
Michaelis, in hospital in study with 75%
Nubling, & Germany survey
Siegel (2002)
Hollingdale & 168 nurses in 2 Cross-sectional QUAN-NR X X X
Warin (1997) hospitals in study with 75%
United Kingdom survey
Holtermann, 5,046 health 1-year QUAN-NR X X
Clausen, care workers prospective 75%
Jørgensen, in unknown study with
Burdorf, & number of survey and
Andersen (2013) long-term care interview
facilities in
Denmark
Horneij, Jensen, 443 NAs in home 18-month QUAN-NR X X X X
Holmström, & health care prospective 75%
Ekdahl (2004) facilities in study with
Sweden survey
Jang et al. (2007) 21 health care Cross-sectional QUAN-NR X X X
workers in survey 75%
hospital in and direct
United States observation

(continued)

765
 Table 1: (continued)

766
Reporting Period and Type Body Region

MMAT Life- 12- Cur- 3–6 Lost Upper Lower

Author Study Population Study Design Criteriaa time Mon rent Months MSD Days Back Shoulder Neck Extremity Extremity

Jensen et al. 163 health care 2-year QUAN-NR X X X

(2006) workers in prospective 100%
hospital in randomized
Denmark control
trial with
observation
and survey
Johnsson, 51 health care 6-month QUAN-NR X X
Carlsson, & workers in prospective 75%
Lagerström hospitals and study with
(2002) homes in observation
Sweden and survey
Josephson, 285 health care 3-year QUAN-NR X X X X
Lagerstrom, workers in prospective 75%
Hagberg, & hospital in study with
Hjelm (1997) Sweden survey
June & Cho (2010)1,345 nurses in Cross-sectional QUAN-DE X X
22 hospitals in study with 75%
South Korea survey
Karahan, Kav, 1,600 health care Cross-sectional QUAN-NR X X
Abbasoglu, & workers in 6 study with 100%
Dogan (2009) hospitals in survey
Turkey
Kee & Seo (2007) 162 nurses in Cross-sectional QUAN-NR X X X X X X
hospitals in study with 50%
South Korea survey

(continued)
 Table 1: (continued)

Reporting Period and Type Body Region

MMAT Life- 12- Cur- 3–6 Lost Upper Lower

Author Study Population Study Design Criteriaa time Mon rent Months MSD Days Back Shoulder Neck Extremity Extremity

Kim, Dropkin, 12,357 RNs, 7-year QUAN-NR X X X X

Spaeth, Smith, 5,397 NAs, and retrospective 100%
& Moline (2012) 29,589 other study using
workers in 15 compensation
hospitals in records
United States
Kim et al. (2014) 978 nurses, 86 Cross-sectional QUAN-NR X X X X X
PCAs, and study with 100%
275 others in survey
2 hospitals in
United States
Kjellberg, 102 nurses from Laboratory study QUAN-NR X X X X
Lagerström, & hospitals in investigating 75%
Hagberg, (2003) Sweden different lifting
devices
Knibbe & Frielle 189 RNs and 165 6-month QUAN-NR X X X X X X X X X
(1996) NAs in homes in prospective 100%
Netherlands study with
survey
Knibbe & Frielle 298 nurses 12-month QUAN-NR X X
(1999) in home prospective 100%
health care in study using
Netherlands logs and
surveys
Koehoorn, Cole, 5,029 health 10-year QUAN-NR X X X X X
Hertzman, & Lee care workers retrospective 75%
(2006) in 1 hospital in case-control
Canada study using
compensation

767
records

(continued)
 Table 1: (continued)

768
Reporting Period and Type Body Region

MMAT Life- 12- Cur- 3–6 Lost Upper Lower

Author Study Population Study Design Criteriaa time Mon rent Months MSD Days Back Shoulder Neck Extremity Extremity

Koehoorn, 3,769 health 3-year QUAN-NR X X

Demers, care workers retrospective 75%
Hertzman, in 1 hospital in study using
Village, & Canada company injury
Kennedy (2006) records
Kromark, Dulon, 834 RNs and Cross-sectional QUAN-DE X X X
Beck, & 556 NAs in 68 study with 75%
Nienhaus (2009) long-term care survey and
facilities and 18 examination
home health
services in
Germany
Kulkarni & 25 nurses in a Cross-sectional QUAN-NR X X X X X
Darsana (2014) hospital in India study with 50%
survey
Lagerstrom, 165 RNs, 255 Cross-sectional QUAN-NR X X X X X X
Wenemark, NAs, and 268 study with 100%
Hagberg, Hjelm, auxiliary nurses survey
& the Moses in hospital in
Study Group Sweden
(1995)
Lagerstrom et al. 348 health care 3-year QUAN-DE X X X X X X
(1998) workers in prospective 100%
hospital in study with
Sweden survey

(continued)
 Table 1: (continued)

Reporting Period and Type Body Region

MMAT Life- 12- Cur- 3–6 Lost Upper Lower

Author Study Population Study Design Criteriaa time Mon rent Months MSD Days Back Shoulder Neck Extremity Extremity

Lamy et al. (2014) 1,896 RNs and 2-year QUAN-NR X X

NAs in 7 prospective 100%
hospitals in study with
Finland survey
Landry, Raman, 344 health care Cross-sectional QUAN-NR X X X
Sulway, workers in study with 100%
Golightly, & hospital in survey
Hamdan (2008) Kuwait
Lee, Faucett, 361 nurses in Cross-sectional QUAN-NR X X X X
Gillen, Kraus, & national society study with 75%
Landry (2010) in United States survey
Lee & Chiou 3,159 nursing Cross-sectional QUAN-NR X X
(1994) personnel in study with 100%
hospitals in survey
Taiwan
Leighton & Reilly 1,134 nursing Cross-sectional QUAN-NR X X X X
(1995) personnel in study with 100%
hospitals in survey
United Kingdom
Lin, Tsai, Chen, & 217 nurses in Cross-sectional QUAN-DE X X X
Huang (2012) 1 hospital in study with 100%
Taiwan survey
Lipscomb, Trinkoff, 1,163 RNs in Cross-sectional QUAN-NR X X X X
Brady, & Geiger- health care study with 75%
Brown (2004) facilities in 2 survey
states of United
States

769
(continued)
 Table 1: (continued)

770
Reporting Period and Type Body Region

MMAT Life- 12- Cur- 3–6 Lost Upper Lower

Author Study Population Study Design Criteriaa time Mon rent Months MSD Days Back Shoulder Neck Extremity Extremity

Luime et al. (2004) 769 caregivers in 2-year QUAN-NR X X X

homes in the prospective 50%
Netherlands study with
survey
Lusted, Carrasco, 64 nurses in 1 Cross-sectional QUAN-DE X X X X X X X X
Mandyk, & hospital in study with 50%
Healey (1996) Australia survey
and 1-year
retrospective
study with
compensation
records
Majumdar, Pal, 627 nurses in Cross-sectional QUAN-NR X X X X X X X X
& Majumdar military hospitals study with 75%
(2014) in India survey
Maul, Läubli, 1,195 nurses 8-year QUAN-DE X X X
Klipstein, & in hospital in prospective 100%
Krueger (2003) Germany study with
survey
Mendelek, Caby, 90 RNs, 94 NAs, Cross-sectional QUAN-NR X X
Pelayo, & Kheir and 52 other study with 50%
(2013) health care survey
workers in
1 hospital in
Lebanon
Moreira, Sato, 245 nurse Cross-sectional QUAN-NR X X X X X X X
Foltran, Silva, & technicians study with 75%
Coury (2014) and LPNs in a survey
hospital in Brazil
(continued)
 Table 1: (continued)

Reporting Period and Type Body Region

MMAT Life- 12- Cur- 3–6 Lost Upper Lower

Author Study Population Study Design Criteriaa time Mon rent Months MSD Days Back Shoulder Neck Extremity Extremity

Munabi, 775 nurses in 5 Cross-sectional QUAN-NR X X X X X X

Buwembo, hospitals in study with 100%
Kitara, Ochieng, Uganda survey
& Mwaka (2014)
Nabe-Nielsen, 184 RNs and 164 Cross-sectional QUAN-NR X X
Fallentin, other nursing study with 100%
Christensen, personnel in survey
Jensen, & hospital in
Diderichsen Denmark
(2008)
Niedhammer, 469 nurses in 6 10-year QUAN-NR X X X
Lert, & Marne hospitals in prospective 75%
(1994) France study with
survey
Owen, Garg, & 38 NAs in long- Cross-sectional QUAN-NR X X
Jensen (1992) term facilities in study with 100%
United States survey
Pahlevan, 286 RNs from a Cross-sectional QUAN-NR X X X X X X
Azizzadeh, hospital in Iran study with 100%
Esmaili, survey
Ghorbani,
& Mirmoham-
madkhani (2014)
Punnett (1987) 76 health care Cross-sectional QUAN-NR X X X
personnel in study with 50%
hospital in survey
United States

(continued)

771
 Table 1: (continued)

772
Reporting Period and Type Body Region

MMAT Life- 12- Cur- 3–6 Lost Upper Lower

Author Study Population Study Design Criteriaa time Mon rent Months MSD Days Back Shoulder Neck Extremity Extremity

Qin, Kurowski, 733 NAs, 216 Cross-sectional QUAN-NR X X X

Gore, & Punnett LPNs, 238 RNs, study with 100%
(2014) and 286 other survey
health care and 7-year
professionals retrospective
in long-term study with
care facilities in compensation
United States records
Reed, Battistutta, 416 nurses in Cross-sectional QUAN-NR X X X X X
Young, & pediatric study with 100%
Newman (2014) hospital in survey
Australia
Reme, Dennerlein, 1,572 health care Cross-sectional QUAN-NR X X X
Hashimoto, & workers in 2 study with 100%
Sorensen (2012) hospitals in survey
United States
Retsas & 269 RNs in Cross-sectional QUAN-NR X X X X X X
Pinikahana medical center study with 100%
(2000) in Australia survey
Serranheira, 62,566 RNs Cross-sectional QUAN-NR X X X X X
Cotrim, in unknown study with 75%
Rodrigues, number of national survey
Nunes, & hospitals, home
Sousa-Uva health, long-
(2012) term care and
other facilities in
Portugal
(continued)
 Table 1: (continued)

Reporting Period and Type Body Region

MMAT Life- 12- Cur- 3–6 Lost Upper Lower

Author Study Population Study Design Criteriaa time Mon rent Months MSD Days Back Shoulder Neck Extremity Extremity

Serranheira, 2,140 RNs in Cross-sectional QUAN-NR X X X X

Cotrim, unknown study with 75%
Rodrigues, hospitals and survey
Nunes, & health care
Sousa-Uva centers in
(2012) Portugal
Schluter, Dawson, 4,903 nurses and Cross-sectional QUAN-NR X X
& Turner (2014) midwives in study with 75%
Australia and survey
New Zealand
Smedley, Egger 1,659 nurses in Cross-sectional QUAN-NR X X X X
P, Cooper, & hospitals in study with 100%
Coggon (1995) United Kingdom survey
Smedley, Egger 961 nursing 2-year QUAN-NR X X X
P, Cooper, & personnel in prospective 75%
Coggon (1997) hospital in study with
United Kingdom survey and
company
records
Smedley et al. 587 nurses at 13 month QUAN-NR X X X
(2003) 2 hospitals in prospective 100%
United Kingdom study with
survey
Smedley, Inskip, 1,366 nurses in 2-year QUAN-NR X X
Buckle, Cooper, 3 hospitals in prospective 100%
& Coggon (2005) United Kingdom study with
survey
(continued)

773
 Table 1: (continued)

774
Reporting Period and Type Body Region

MMAT Life- 12- Cur- 3–6 Lost Upper Lower

Author Study Population Study Design Criteriaa time Mon rent Months MSD Days Back Shoulder Neck Extremity Extremity

Smith, Choi, 91 nursing Cross-sectional QUAN-DE X X X X X X

Ki, Kim, & personnel in study with 100%
Yamagata (2003) nursing home in survey
South Korea
Smith, Sato, 222 nursing Cross-sectional QUAN-DE X X X X X X
Miyajima, students in study with 75%
Mizutani, & Japan survey
Yamagata (2003)
Smith, Wei, Kang, 180 RNs in Cross-sectional QUAN-NR X X X X X X
& Wang (2004) hospital in China study with 100%
survey
Smith, Mihashi, 844 nurses in Cross-sectional QUAN-NR X X X X
Adachi, Koga, & hospital in study with 100%
Ishitake (2006) Japan survey
Smith & Leggat 260 nursing Cross-sectional QUAN-DE X X X X X X
(2004) students in study with 25%
Australia survey
Sopajareeya, 241 RNs, 22 Cross-sectional QUAN-NR X X
Viwatwong- technical study with 100%
kasem, Lapvong- nurses, and 2 survey
watana, Hong, practical nurses
& Kalampakorn in 1 hospital in
(2009) Thailand
Stobbe, Plummer, 143 LPNs, 252 3-year QUAN-NR X X
Jensen, & NAs, and retrospective 75%
Attfield (1998) 20 ATTs in 1 study using
hospital in company injury
United States records

(continued)
 Table 1: (continued)

Reporting Period and Type Body Region

MMAT Life- 12- Cur- 3–6 Lost Upper Lower

Author Study Population Study Design Criteriaa time Mon rent Months MSD Days Back Shoulder Neck Extremity Extremity

Stubbs, Buckle, 3,912 nurses in Cross-sectional QUAN-NR X X X X X

Hudson, Rivers, hospitals in study with 75%
& Worringham United Kingdom survey
(1983)
Swain, Pufahl, 138 nursing Cross-sectional QUAN-NR X X
& Williamson students in study with 75%
(2003) United Kingdom survey
Takala & 143 nurses in 5 Cross-sectional QUAN-NR X X X X
Kukkonen (1987) hospitals in survey and 100%
Finland video analysis
Tezel (2005) 120 nursing Cross-sectional QUAN-DE X X X X
personnel in study with 100%
4 hospitals in survey
Turkey
Theodora, 135 nursing Cross-sectional QUAN-DE X X
Dimosthenis, personnel in study with 75%
Michael, a hospital in survey
Athanasios, & Greece
Evaggelos (2005)
Tinubu, Mbada, 128 nurses in 3 Cross-sectional QUAN-NR X X X X X X
Oyeymi & hospitals in study with 100%
Fabunmi (2010) Nigeria survey
Trinkoff, Brady, & 1,163 licensed Cross-sectional QUAN-NR X X X X
Nielson (2003) nurses in study with mail 100%
hospitals, long- survey
term facilities,
and homes in
United States

775
(continued)
 Table 1: (continued)

776
Reporting Period and Type Body Region

MMAT Life- 12- Cur- 3–6 Lost Upper Lower

Author Study Population Study Design Criteriaa time Mon rent Months MSD Days Back Shoulder Neck Extremity Extremity

Trinkoff, Lipscomb 1,163 licensed Cross-sectional QUAN-DE X X X X X

J, Geiger-Brown, nurses in study with 100%
& Brady (2002) hospitals, long- survey
term facilities,
and homes in
United States
Trinkoff, Le, 2,273 nurses in 15-month QUAN-DE X X X X
Geiger-Brown, United States prospective 100%
Lipscomb, & study with
Lang (2006) survey
Vasihadou, 407 nurses in Cross-sectional QUAN-NR X X X X
Karvountzis, hospital in study with 100%
Soumilas, Greece survey
Roumeliotis, &
Theodoso-
poulou (1995)
Videman, Ojaja, 174 nursing 7.5 year QUAN-NR X X
Riihima, & students in prospective 100%
Troup, (2005) Finland study using
survey
Vieira, Kumar, 47 nurses at Cross-sectional QUAN-DE X X X X
Coury, & hospital in study with 100%
Narayan (2006) Canada survey
Violante et al. 587 RNs, 228 Cross-sectional QUAN-NR X X
(2004) NAs, and 43 study with 100%
head nurses in survey
hospital in Italy
(continued)
 Table 1: (continued)

Reporting Period and Type Body Region

MMAT Life- 12- Cur- 3–6 Lost Upper Lower

Author Study Population Study Design Criteriaa time Mon rent Months MSD Days Back Shoulder Neck Extremity Extremity

Warming, Precht, 113 RNs and Cross-sectional QUAN-NR X X X X X

Suadicani, & 35 NAs in study with 100%
Ebbehøj (2009) hospital in the survey
Netherlands
Wergeland et al. 19 RNs, 107 NAs, Cross-sectional QUAN-NR X X X X X
(2003) 39 home nurses, study with 75%
57 practical survey
nurses, and 64
other in long-
term facilities
and home
health care in
Norway and
Sweden
Yip (2001) 377 nurses in 6 Cross-sectional QUAN-NR X X
hospitals in study with 100%
Hong Kong survey

Note. MMAT = Mixed Methods Appraisal Tool; MSD = musculoskeletal disorder; RN = registered nurse; NA = nursing assistant; LPN = licensed practical nurse; LVN = licensed
vocational nurse; PCA = patient care assistant; ATT = nurse attendant.
a
MMAT criteria is based on the checklist developed by Pluye and Hong (2014), which assesses quantitative studies with randomized designs (QUAN-R), quantitative studies
with nonrandomized designs (QUAN-NR), quantitative descriptive study (QUAN-DE), qualitative studies (QUAL), and mixed methods (MM). Each study design had three or four
criteria: all criteria satisfied = 100%, one criterion not fulfilled = 75% for four and 66% for three, two criteria not fulfilled = 50% for four and 33% for three, three criteria not
fulfilled = 25% for four, and no criteria fulfilled = 0%. Shaded studies were eliminated from analysis based on less than 25% of criteria fulfilled.

777
778
100
90
Percentage of Populaon (%)
80
70
65
60
50
40
30
20
10
Lifeme
Figure 1. Prevalence of low back pain as a function of pain outcome: lifetime, previous 12 months,
current (less than 7 days), 3 to 6 months, musculoskeletal disorder injury, and lost-time injury.
authors (67%) investigated nurses (registered or
licensed), and 24% of the study authors investi-
gated nursing aides. Approximately 28% of the
studies included populations with more general
health care workers or a nondesignated nursing
and nursing aide population. The bottom line
is that authors of most studies have assessed
pain and injuries utilizing a self-reported cross-
sectional survey, which is good to understand
pain frequency.
The authors of the majority of studies investi-
gated pain in the past 12 months (57%), fol-
lowed by current pain (less than 7 days; 37%),
lifetime pain (15%), and 3 to 6 months (10%).
Authors of few studies investigated actual
reported injuries (10%) or injuries with lost days
(14%). When looking at the body regions,
almost all of the researchers investigated pain in
the low back (93%), with fewer researchers
investigating MSD pain in the neck (47%) and
shoulder (46%), upper extremity (27%), and
lower (30%) extremities.
A summary of the prevalence for each body
region as a function of outcome type is found in
August 2015 - Human Factors
Low Back
55
44
35
20
14
Annual Current 3 to 6 MSD Injury Lost Time
months Injury
Figures 1 to 5. With the most data points, mean
prevalence for low-back pain (Figure 1) was
65% for lifetime, 55% for previous year, 44%
for previous 3 to 6 months, and 35% for current
symptoms. Actual reported low-back injuries
(MSDs reported in company injury reports)
occurred in only 14% of nurses, and self-
reported lost-day injuries occurred in 20%.
Shoulder prevalence was slightly lower (Figure
2): lifetime at 54%, past year at 44%, past 3 to 6
months at 44%, current at 32%, reported MSDs
at 24%, and subjective lost days at 12%. There
were no data for lifetime prevalence for neck
pain (Figure 3) and 42%, 48%, and 28% for past
year, past 3 to 6 months, and current pain,
respectively. The prevalence for reported neck
injuries was 20% and for lost-day injuries was
around 7%, although few studies went into these
estimates. In Figure 4, the average prevalence of
upper-extremity pain in past year and 3 to 6
months was 26% and 21%, respectively. Current
upper-extremity pain prevalence was 15%.
Again, authors of few studies investigated
upper-extremity MSDs with a prevalence around
MSD Pain in Nursing Workers 779

90
Shoulder
80
Percentage of Populaon (%)

70

60
54
50
44 44
40

30 32

24
20

12
10

Lifeme Annual Current 3 to 6 MSD Injury Lost Time

months Injury

Figure 2. Prevalence of shoulder pain as a function of pain outcome: lifetime, previous 12 months,
current (less than 7 days), 3 to 6 months, musculoskeletal disorder injury, and lost-time injury.

90
Neck
80
Percentage of Populaon (%)

70

60

50 48
No
40 Data 42

30 28

20 20

10
7
0

Lifeme Annual Current 3 to 6 MSD Injury Lost Time

months Injury

Figure 3. Prevalence of neck pain as a function of pain outcome: lifetime, previous 12 months,
current (less than 7 days), 3 to 6 months, musculoskeletal disorder injury, and lost-time injury.
780
70
Upper Extremity
60
Percentage of Populaon (%)
50
40
30 No
Data 26
20
10
Lifeme Annual
Figure 4. Prevalence of upper-extremity pain as a function of pain outcome: lifetime, previous 12 months,
current (less than 7 days), 3 to 6 months, musculoskeletal disorder injury, and lost-time injury.
8%. No data have been reported for lifetime prev-
alence or lost-day injuries for upper-extremity
pain outcomes. For the lower-extremity pain
outcomes (Figure 5), mean past yearly preva-
lence was 36%, and the 3- to 6-month and cur-
rent prevalence were 38% and 20%, respec-
tively. Again, authors of few studies investigated
the report injuries (6% of workers reporting
MSDs) and lost-time injuries (8% on average).
No data have been published for lifetime preva-
lence of lower-extremity pain.
The prevalence as a function of nursing cate-
gory and health care facility is in Table 2. In gen-
eral, the table of prevalence was sparse in many
cells particularly with respect to lifetime pain and
injuries (either reported or subjective lost time) as
well as non-low-back pain outcomes in home
health care and long-term care facilities. By far,
low-back pain had the most cells filled with val-
ues. The prevalence for mixed populations (nurses,
nursing aides, and other health care workers)
tended to have higher prevalence of low-back pain
than nurses or nursing aides by themselves. Hos-
pitals had more studies investigating low-back
August 2015 - Human Factors
No
21 Data
15
8
Current 3 to 6 MSD Injury Lost Time
months Injury
pain than either long-term care or home health
care facilities. Although the prevalence of low-
back pain varied among the different facilities as
well as nurses and nursing aides, the trends were
not consistent. Authors of a large number of the
studies investigated nurses who work at hospitals
for low-back outcomes. For shoulder pain, the
majority of cells were empty or had just a few
studies. Nurses in hospitals were the most widely
studied group for shoulder pain, with a mean prev-
alence of 44%. Home health care may be slightly
more risky for shoulder pain (35%), but limited
studies may undermine the estimates. Similar
trends were found for the neck, upper-extremity,
and lower-extremity pain outcomes—lack of evi-
dence in many cells, some trending to higher lev-
els in home health care, and not a lot of consistent
trends.
Discussion
Given the studies on the reported preva-
lence of MSDs in nurses and nursing aides,
it was apparent that high levels of pain were
experienced over the course of a year, with the
MSD Pain in Nursing Workers
70
Lower Extremity
60
Percentage of Populaon (%)
50
40
36
30
No
Data
20
10
Lifeme Annual
Figure 5. Prevalence of lower-extremity pain as a function of pain outcome: lifetime, previous 12 months,
current (less than 7 days), 3 to 6 months, musculoskeletal disorder injury, and lost-time injury.
highest levels in the lower back, shoulder, and
neck areas. Although there is a critical mass of
studies for these body regions and follow-up
time frame, focusing on the yearly prevalence
provides flawed representation of the pain and
suffering for nurses as it does not capture the
transient nature of pain. As our tracking systems
and statistical procedures expand to handle big
data, the capturing of instantaneous pain in these
body regions may lead to a better understand-
ing of the risk factors driving the injuries. One
of the potential issues with nurses is that they
have so many different risk factors they deal
with on a given day, from interacting with sick
patients to being on their feet for long periods to
handling many materials (Poole Wilson, Davis,
Kotowski, & Daraiseh, 2015). If one adds the
mental and potential stress demands for a typi-
cal 12-hr shift, one has a complex set of risk fac-
tors that could all contribute to the pain suffered
by the nurses.
Obviously, many researchers (Bakker et al.,
2009; Buckle, 1987; Kuiper et al., 1999; Nelson
& Baptiste, 2006) have shown a link between
low-back pain in nurses and patient handling,
781
38
20
6 8
Current 3 to 6 MSD Injury Lost Time
months Injury
which requires lifting and repositioning of heavy
patients. Shoulder injuries and pain could poten-
tially be related to the repositioning of the patient
in the bed when the nurse leans over the bed and
uses his or her upper body to slide a patient up in
bed or turn the patient on his or her side; both are
routine tasks performed by nurses (Poole Wilson
et al., 2015). Although few study authors have
investigated MSDs in upper and lower extremi-
ties, there are potentially many risk factors that
may contribute to MSDs in the extremities,
including standing and walking for long periods
on hard surfaces or slips for the lower extremity
and chart entry on electronic medical record
devices and more-hand-intensive procedures to
patient for upper extremity. However, the cur-
rent review has focused on identifying the
reported prevalence of adverse outcomes for
nurses and cannot provide any direct insight into
the underlying risk factors.
One take-home message from the current
review is that studies are limited in the types of
MSD outcomes and facilities. Table 2 has too
many empty cells or cells with only a single
study to draw conclusions of the prevalence of
 Table 2: Summary of the Mean Prevalence for Different Pain Outcomes as a Function of Health Facility and Health Care Worker (number of studies

782
in parentheses)

Body Region Facility Health Care Worker Lifetime Past Year 3 to 6 Months Current MSD Injury Lost-Time Injury

Low back Hospital Nurses 66 (18) 55 (52) 37 (2) 34 (24) 14 (1) 14 (9)
Nursing aides 58 (2) 40 (6) 24 (3) 31 (2)
Mixed 77 (3) 65 (16) 55 (5) 39 (8) 11 (4) 35 (1)
Home health Nurses 40 (1)
Nursing aides 62 (1) 33 (2)
Mixed 59 (3) 21 (5) 3 (1) 31 (1)
Long-term care Nurses 42 (2) 34 (1)
Nursing aides 30 (1) 38 (1) 68 (2) 25 (3)
Mixed 18 (2) 16 (1)
Mixed Nurses 53 (5) 61 (1)
Nursing aides 19 (1) 48 (1) 55 (1) 14 (1)
Mixed 50 (4) 38 (3) 26 (1)
Shoulder Hospital Nurses 52 (2) 44 (23) 28 (1) 31 (5) 19 (2)
Nursing aides 60 (1) 24 (1)
Mixed 35 (8) 43 (1) 36 (3) 6 (2)
Home health Nurses 53 (1)
Nursing aides 66 (1)
Mixed 73 (1) 53 (2) 38 (3)
Long-term care Nurses 27 (3)
Nursing aides
Mixed
Mixed Nurses 33 (3) 22 (2) 17 (1)
Nursing aides
Mixed 48 (8) 51 (2) 55 (1)

(continued)
 Table 2: (continued)

Body Region Facility Health Care Worker Lifetime Past Year 3 to 6 Months Current MSD Injury Lost-Time Injury

Neck Hospital Nurses 41 (22) 39 (1) 27 (11) 1 (1) 10 (1)

Nursing aides 12 (1)
Mixed 40 (11) 45 (3) 6 (2)
Home health Nurses
Nursing aides 59 (1)
Mixed 63 (1) 57 (2) 29 (4)
Long-term care Nurses 23 (3)
Nursing aides
Mixed 11 (1)
Mixed Nurses 57 (1)
Nursing Aides
Mixed 45 (9) 24 (3) 30 (2)
Upper extremity Hospital Nurses 27 (14) 15 (1) 17 (4) 11 (2)
Nursing aides 30 (1) 29 (2) 13 (1)
Mixed 25 (9) 14 (4) 2 (1)
Home health Nurses
Nursing aides
Mixed 25 (2) 12 (1) 14 (1)
Long-term care Nurses 6 (1)
Nursing aides
Mixed
Mixed Nurses 24 (1)
Nursing aides
Mixed 21 (1) 2 (1)
(continued)

783
784
Table 2: (continued)

Body Region Facility Health Care Worker Lifetime Past Year 3 to 6 Months Current MSD Injury Lost-Time Injury

Lower extremity Hospital Nurses 35 (17) 30 (1) 24 (6) 8 (2)

Nursing aides 30 (2)
Mixed 38 (8) 52 (2) 18 (4) 7 (2)
Home health Nurses
Nursing aides
Mixed 43 (2) 18 (1) 15 (1)
Long-term care Nurses 10 (1)
Nursing aides
Mixed
Mixed Nurses 34 (1)
Nursing aides
Mixed 21 (1) 5 (1)

Note. MSD = musculoskeletal disorder.

MSD Pain in Nursing Workers
many of the MSD outcomes for anything but
low-back pain in hospitals. The bottom line is
that because of the primary focus on low-back
pain for nurses, researchers may be neglecting
many of the other injuries that the nursing pro-
fession faces, and with new procedures and
devices, these risk factors are likely to continue
to change and impact different body regions.
Another major conclusion drawn from the
review was that few studies focused on more
serious MSD outcomes, such as reported MSDs
and lost-day cases. Although evaluating yearly
pain is easier as one needs only a single survey,
information about more serious cases is lost
(Ferguson & Marras, 1997). Furthermore, the
majority of the studies relied upon subjective
assessments of pain (e.g., self-administered sur-
vey without clinical examination). The subjec-
tive nature of pain may be one underlying factor
for the variability in prevalence of a specific
pain outcome (as seen in Figures 1 to 5). Further,
remembering episodes of pain over a long period
(e.g., 12 months) can be highly subjective and
person dependent, which may also contribute to
the variability in prevalence across studies. The
subjective nature of the pain assessments and
long observation times make it difficult to iden-
tify the real casual factors for the injuries, espe-
cially in such a complex environment. Although
patient handling is the big elephant in the room,
many factors are likely to contribute to progres-
sion of MSDs in nurses.
Reported prevalence values may also be a
function of when the study was conducted. By
scanning Table 2, one sees that authors of few
studies (fewer than 21 studies) investigated
MSD prevalence before 1994, but there is a
steady trend in more studies in the past two
decades (culminating with 14 studies in the past
12 months). By having more studies in recent
years, the prevalence estimates may be more
accurate to the current MSD trends in health
care. Health care is constantly changing, with
new practices and policies that will directly
impact MSDs. A perfect example is the no-lift
policies that will likely reduce low-back inju-
ries, but shoulder injuries may start to increase
as a result of pushing force when moving the
lift-assist devices. In the future, researchers will
need to prove this theory of more diverse types
785
of injuries. The bottom line is that the timing of
the studies (date study collected) may have
influenced the actual observed prevalence levels
of the different MSD outcomes. Furthermore,
these studies also represent the reported preva-
lence, which may not be a completely accurate
estimate of the actual prevalence.
There were some major voids in the under-
standing of musculoskeletal pain in the nursing
profession. First, studies were extremely limited
in the investigation of home health care and
long-term care facilities, with fewer than five
studies in a given pain outcome category. With
the likelihood of increased demands in long-
term care and home health care facilities, it will
be imperative to have a better understanding of
MSDs and pain in these facilities. Home health
care introduces another dimension of ergonomic
risk, with each house representing a unique set
of exposures. Home health care needs to be a
high priority in both understanding ergonomic
exposures and developing flexible interventions
that are drastically different from the traditional
hospital settings. Second, few researchers have
investigated the upper- and lower-extremity pain
for most of the pain outcome variables. As the
demands, processes, and utilization of lift equip-
ment change, the prevalence of the pain in body
regions other than the low back may increase.
Finally, most studies have utilized subjective
surveys to assess MSD pain, predominantly
assessing yearly pain. As a result, the progres-
sion of MSDs from discomfort to disability has
yet to be fully understood in the health care
industry. Subjective assessments that have been
predominantly conducted for 12-month retro-
spective periods are potentially biased, espe-
cially when determining association with expo-
sures. In all, these voids indicate that there is a
lot of work yet to be done in order to completely
understand the exposures and resulting MSD
outcomes in all types of health care facilities.
Further, the bar will likely continue to change as
health care evolves with different demographics
(e.g., obesity and living longer) and processes.
Worldwide MSD Pain
Another interesting summary of the studies was
how MSDs and corresponding pain impact nurses
and nursing aides across the different regions of
786
the world. For yearly prevalence, Australia/Philip-
pines had the highest prevalence of low-back pain
(71%), followed by Africa (64%) and the Middle
East (58%). The rest of the regions (Europe, North
America, South America, and Asia) had low-back
prevalence between 51% and 57%. Yearly neck
prevalence ranged between 37% (United States/
Canada) to about 48% (Middle East, Asia, South
America, and Europe). Shoulder pain was greatest
in Asia (52%) and Europe (50%) and lowest in
Africa (31%) and North America (35%). Upper-
and lower-extremity pain was less than 30% in
most regions, with the exception of the Middle
East (45% for upper extremity and 52% for lower
extremity). Overall, the North American region
had the lowest prevalence rates, whereas the
Middle East, Asia, and Australia/Philippines had
the highest prevalence of yearly MSD pain across
all body regions. Only one study has involved
investigating pain for nursing in South America.
A slightly different picture of musculoskele-
tal pain was reported for current symptoms. The
Africa region had the highest prevalence for low-
back pain (63%), followed by the United States/
Canada region (43%), Asia (32%), South America
(34%), and Australia/Philippines (24%). Preva-
lence of neck pain was found to be lower than
current low-back pain, with the highest levels in
Africa (41% as reported in one study) and
Europe (37%) and lowest in Asia (about 13%)
and Australia/Philippines (about 20%). For cur-
rent shoulder pain, Australia/Philippines (11%)
had the lowest prevalence, whereas Europe
(40%) and Africa (41%) were at the highest. The
United States/Canada had a mean current preva-
lence of about 20%. Across the world, the num-
ber of studies on current upper and lower
extremities was small, with most of them report-
ing below 15% to 20% for current pain. The
only exception was one study in Africa (24% for
upper extremity and 40% for lower extremity).
For current pain, the general trend was that the
lowest prevalence values were found in Austra-
lia/Philippines, whereas the highest values were
in Africa. However, few studies have been per-
formed in Africa.
Although the current review cannot provide
insight into underlying reasons for the differ-
ences between world regions, one may provide
conjecture about the underlying factors. The
August 2015 - Human Factors
largest differences between regions were for
low-back pain, whereby less developed coun-
tries had significantly higher prevalence levels.
These regions also had the smallest number of
studies, which may be reflective of some bias
(e.g., overreporting in a few studies) or lack of
infrastructure (e.g., limited use of lift-assist
devices). Because the number of studies in a
given region is liable to be directly related to the
number of countries, the differences between
developing and developed regions in low-back
pain is likely due to better equipment and work-
ing environments. Future research with multina-
tional investigators may shed more light into
these differences. Many factors may contribute
to the differences between world regions for the
other body regions, with the most likely cause
being different exposures during the treatment
of patients. Another review of the actual expo-
sures identified in different countries could pro-
vide valuable insight into what is driving the dif-
ferent prevalence levels.
Future Impact of MSD in Health Care
With an increase in the number of facilities
adopting “no-lift” policies, prevalence rates
may be trending down for nurses and nursing
aides. As the effectiveness of these programs
increases due to improvements in leadership,
training, and accessibility of equipment, preva-
lence of MSDs, specifically low back, will
likely continue to decrease in health care facili-
ties. However, MSDs in the shoulders and upper
extremity may actually increase as the physical
demands change from lifting patients to pushing
lifting-assist devices and other medical equip-
ment. For this reason, future epidemiological
studies on pain and injuries in nurses and nurs-
ing aides will need to focus on shoulders and
upper extremities and go beyond the traditional
focus on the low-back region.
Another major factor in future MSDs in
health care could be the shift to early mobility
whereby other health care providers besides
nurses and nursing aides interact with the patient.
Early mobility has increasingly become a
responsibility of physical therapists (Perme &
Chandrashekar, 2009). Physical therapists are
required to handle patients with varying levels
of physical function due to muscle atrophy,
MSD Pain in Nursing Workers
disease or infection, or drug-induced delirium
(Perme & Chandrashekar, 2009). Physical thera-
pists may be the worker population that is at
most risk in the near future as this integration of
patient mobility becomes commonplace in all
health facilities. To date, authors of few studies
(seven studies) have investigated the prevalence
of MSDs for physical therapists. In these stud-
ies, the MSD pain in the previous 12 months was
lower for physical therapists than nurses: low
back-pain at 39% versus 55%, shoulder pain at
14% versus 44%, neck pain at 20% versus 42%,
upper-extremity pain at 20% versus 26%, and
lower-extremity pain at 6% versus 36%, respec-
tively (Bork et al., 1996; Campo, Weiser, &
Koenig, 2009; Campo, Weiser, Koenig, & Nor-
din, 2008; Cromie, Robertson, & Best, 2000;
Holder et al., 1999; Molumphy, Unger, Jensen,
& Lopopolo, 1985). Other studies have shown
similar relative values for lifetime pain (Cromie
et al., 2000; Salik & Özcan, 2004).
Limitations of Current Review
Although the review has provided poten-
tially valuable insight into the prevalence of
MSDs in nurses and nursing aides, several
potential limitations need to be discussed. First,
the review was for the most part inclusive of
all the articles that evaluated prevalence of
MSDs. We did use the MMAT (Pluye & Hong,
2014) to rate the quality of the articles, with the
lowest-quality articles being eliminated from
the review. Second, only articles published in
English were included. This criterion may have
resulted in some estimates being neglected
in non-English-speaking countries. Third, the
review concentrates on the health outcome and
neglects the underlying risk factors. A complete
understanding of the impact of MSDs on the
nursing profession will require quantification
of risk factors, which other reviews have done
(Bakker et al., 2009; Buckle, 1987; Kuiper et
al., 1999; Nelson & Baptiste, 2006). The current
review complements these previous reviews by
highlighting who is at risk of MSD injuries and
pain and specifically for nurses and nursing
aides. Finally, the current review concentrated
on prevalence and not actual incidence rates.
Obviously, injury rate would take into account
the number of nurses or nursing aides who were
787
exposed to MSD risk factors. However, studies
on incidence rates were more infrequent than
those on prevalence (29 vs. 88, respectively),
making it difficult to draw inferences with
respect to health outcomes, especially when
one starts to break prevalence rates down to the
different types and body regions. Given these
potential limitations, the review was robust in its
inclusion criteria, which allowed for the identi-
fication of missing data for the English literature
as a whole.
Conclusion
Although MSD pain in the nursing profes-
sion appears to have been broadly investigated
worldwide, there were several major voids in the
literature. First, the majority of authors investi-
gated MSD pain in nurses and nursing aides in
hospitals. Few researchers have investigated
MSD pain for nurses and nursing aides in home
health care and long-term care facilities (fewer
than five studies in a given pain outcome cate-
gory). Second, few authors have investigated the
upper- and lower-extremity regions for most of
the MSD pain outcome variables. With changes
in demands and expected increased usage of lift-
assist devices and other safe patient-handling
equipment, it will be imperative to understand
the pain and injuries in the extremities. Finally,
most studies have utilized subjective surveys to
assess MSD pain, predominantly in the previ-
ous year. Better clinical diagnoses will improve
the understanding of MSD pain. Given many
environmental and social changes in the health
care industry, including living longer with more
chronic diseases, bariatric patients, early mobil-
ity, and wanting to be at home during sickness,
higher prevalence levels may shift to differ-
ent populations—home health care and long-
term care nurses—as well as in different body
regions, such as shoulders and upper extremity.
Future research will be needed to track these
potential shifts in pain, away from a focus on
low-back pain for nurses in hospitals.
Acknowledgments
Partial funding was provided by Hill-Rom, Inc.,
to conduct this literature review and provide a solid
foundation for researchers investigating musculo-
skeletal disorders in health care.
788
Key Points
•• Authors of a majority of the studies investigated
musculoskeletal disorder (MSD) pain in nurses
and nursing aides in hospitals, whereas few stud-
ies have settings in home health care and long-
term care facilities.
•• Authors of few studies have investigated the
upper- and lower-extremity regions for most of
the MSD pain outcome variables.
•• Most studies have utilized subjective surveys to
assess MSD pain, predominantly in the previous
year.
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Kermit G. Davis is an associate professor at the Uni-
versity of Cincinnati in the College of Medicine,
Department of Environmental Health, where he also
directs the Low Back Biomechanics and Workplace
Stress Laboratory. He received his PhD in occupa-
tional ergonomics from The Ohio State University,
College of Engineering, Department of Industrial
and Systems Engineering. He is a certified profes-
sional ergonomist.
Susan E. Kotowski is an assistant professor at the
University of Cincinnati in the College of Allied
Health Sciences. She is also director of the Gait and
Movement Analysis Lab. She received her PhD in
occupational ergonomics and safety from the Uni-
versity of Cincinnati, College of Medicine. She is
also a certified professional ergonomist.
Date received: December 10, 2013
Date accepted: March 20, 2015