UI Proceedings on Health and Medicine Vol.

4 2019

Quality of Nursing Work Life of Associate Nurses and Work-Related

Musculoskeletal Disorders

Eva Sulastri1*, Cut Sarida Pompey2

1.
Bachelor of Nursing, Faculty of Nursing University of Indonesia, Depok 16424, Indonesia
2.
Department of Medical Surgical Nursing, Faculty of Nursing University of Indonesia, Depok 16424, Indonesia

*E-mail: evasulastri05@gmail.com, cut.pompey@ui.ac.id

Abstract
Objective: The aim of study was to identify the relationship between quality of nursing work life (QNWL) of associate
nurses with work-related musculoskeletal disorders (WMDs).
Methods: This descriptive analysis and correlation study used cross sectional design and consecutive sampling
technique.
Results: This study resulted that 51.3% of associate nurses had a high QNWL, the highest subvariabel of job perception
(29.95%), the lowest subvariables relation with the head nurse (11.68%), and 91.3% of associate nurses experienced
low-musculoskeletal disorders.
Conclusion: There was no relationship between the quality of nursing work life of associate nurses with work-related
musculoskeletal disorders (ρ = 0.47, α = 0.05). This means that although the nurse has musculoskeletal disorders, the
quality of work life remains high. Although some nurses do not had WMDs, but some of them have a low quality of
nursing work life.
Keywords: Work-related musculoskeletal disorders, quality of nursing work life, associate nurse

Introduction sex, BMI, duration of work and marital status.3,5 Both

Work-related musculoskeletal disorders are a group of
the muscles disorders, tendons, and painful nerves such
as carpal tunnel syndrome, and tendonitis1 (Canadian
Center for Occupational Health and Safety, 2014). Some
of the most common musculoskeletal disorders include
pinched nerve, sprain, muscle tension, hernia (traumatic
and nontraumatic), pain, swelling, and numbness; carpal
or tarsal syndrome2.
Associate nurses have a high risk due to work-related
musculoskeletal disorders. It has been reported nurses
have experienced work-related musculoskeletal disorders,
and 61.9% of nurses have lower back pain3. It is reported
that 70% nurses at Emergency room of Surakarta
Hospital have a high work-related musculoskeletal
disorders level, as intensive care unit nurse4.
Musculoskeletal disorders are influenced by three factors,
first the individual characteristic factors including age,
occupational factors include ergonomics and manual
handling which also contributes to increasing risk of
musculoskeletal disorder including work position, power,
repetitive motion, duration, awkward position, and load
of objects or tool loads6,7. The third is environmental
factors (physical and psychosocial)5. The physical
environment includes vibration, lighting, and
temperature, while psychosocial factors include negative
attitudes, high levels of stress, monotonous work, low of
job control, high psychosocial demands, and high job
dissatisfaction7. According to Schmidt and Dantas (2012)
the absence of lumbar pain contributes significantly to
improve the quality of nursing work life8.
The quality of nursing work life is all about conducive
and fun environment in the workplace and is a key factor
in determining productivity and better performance9. The
quality of nursing work life consists of five sub-variables,
namely the work environment, the relationship with the
manager (head nurse), work conditions, job perception,
and support services (Sirin & Sokmen, 2015) 10, which are
interconnected with each other.

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 UI Proceedings on Health and Medicine Vol. 4 2019

The impact of lack of fulfillment of these five Table 2. Frequency and Percentages of Associate Nurse
subvariables will cause psychological and physical based on Some Characteristics (N=80)
disturbance. The quality of work life is a psychosocial N
factor that can affect the occurrence of the risk of Characteristics n %
o
musculoskeletal disorders8. It is been identified 1 Sex
psychosocial factors (mental fatigue) had a strong Male 23 28.8
influence on the incidence of musculoskeletal disorders, Female 57 71.3
and the risk level was 2 times higher than respondents 2 Marital status
who did not have psychosocial complaints 3. This gives an Married 75 93.8
indication of the relationship between the quality of Not Married 4 5
Ever been married 1 1.3
nursing work life and work-related musculoskeletal
3 Body Mass Index (BMI)
disorders, but in Indonesia the results of this study cannot Less weight 3 3.8
be used as strong data due to differences in habitual, Normal weight 59 73.8
cultures and work environments. Over weight 15 18.8
Obesity 3 3.8
This study aims to find out the description of the 4 Duration of work experience at
characteristics of the associate nurses, the description of hospital 31 38.75
the quality of nursing work life, the occurrence of 3-10 years 49 61.25
musculoskeletal disorders experienced of associate nurses, ≥ 10 years
5 Duration of work experience at the
and the correlation between the quality of nursing work
unit
life and the work-related musculoskeletal disorders. 3-10 years 48 60
≥ 10 years 32 40
Methods 6 Has had musculoskeletal disorders
Yes 11 13.8
This descriptive analysis and correlation study used cross No 69 86.2
sectional design and consecutive sampling technique 7 Perception of respondents causes
musculoskeletal disorders
among of 80 nurse respondents who worked in public
WMDs 46 57.5
hospital services. Inclusion criteria were 1) associate Another disease 34 42.5
nurse, 2) Working ≥ 3 years, was considered to have 8 Types of WMDs
sufficient experience in nursing implementation (Benner Sprain 6 7.5
in Kozier, 2010)13, 3) working in the inpatient and Cramps 14 17.5
outpatient service which has similar job characteristics in Fracture 1 1.25
terms of manual handling and ergonomics (working in Low Back Pain (LBP) 21 26.25
selected ward in this study). Herniated Nucleus Pulposus 7 8.75
(HNP)
Etc. (Osteoporosis, Rheumatic, 21 26.25
The used questionnaires were associate nurse Osteoarthritis, Lumbosacral
characteristic questionnaires, quality of nursing work life Radiculopathy)
questionnaire, and Nordic Body Map. The quality of No complaints 10 12.5
nursing work life questionnaire modified by Oyoh,
Somantri, and Yudianto (2017) had validity score around
0,456 - 0,867 and Cronbach Alfa = 0.96 11. Nordic Body Table 2 shows that the majority of nurses was female
Map had extremely good internal consistency with (71.3%) and 93.8% nurses have married. Based on
Cronbach's Alpha = 0.896 (moderate to near perfect calculation of BMI, the majority of respondents had
reliability) and the score of prevalence-adjusted bias- normal weight, but there small number respondents who
adjusted kappa (PABAK) = 0.57-0.90. were obese. The average of the length work of the
respondents in the hospital was ≥ 10 years (61.25%).
Results Based on the placement of work in adult and general care
unit, precisely the length work of the respondents in that
area was around most 3 to10 years (60%). It is shown that
Associate Nurses Characteristics
69 respondents (86.2%) claimed to have no
musculoskeletal disorders during working in adult and
Table 1. Associate Nurses Characteristic Based on Age
(N=80) general care unit. However, the nearly half respondents
had perception that the causes of musculoskeletal disorder
Mean SD Min-Max 95% CI were Work-related musculoskeletal disorders (WMDs)
Age 34.66 4.42 24-47 33.68-35.65 around 57.5%. The most common types of work-related
musculoskeletal disorders were low back pain (26.25%)
and cramp (17.5%). Herniated Nucleus Pulposus (HNP)
was only suffered by 8.75 % of respondents.
Table 1 refer to range of associate nurses' age between 24 Osteoporosis, Rheumatic, Osteoarthritis, and Lumbosacral
to 47 years old, standard deviation 4,42.

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 UI Proceedings on Health and Medicine Vol. 4 2019

Radiculopathy were identified as work-related Table 5 shows that 91.3% of respondents had low
musculoskeletal disorders among respondents. worked-related musculoskeletal disorders. Surprisingly,
this study found that there was no associate nurse who
The Quality of Nursing Work Life (QNWL) had experienced in high and very high of worked-related
musculoskeletal disorders.
Table 3. Frequency Distribution and Percentages of QNWL
of Associate Nurses (N=80) Quality of Nursing Work Life of Associate Nurses and
Quality of Nursing Work Life Work-Related Musculoskeletal Disorders
n %
of Associate Nurses
High 41 51.25 Table 6. Relationship between QNWL of Associate Nurses
Low 39 48.75 and WMDs (N=80)

WMDs ρ
OR
QNWL Low Moderate value
Base on table 3, majority of associate nurses who have
higher quality of nursing work life (51.25%), while who n % n %
have low quality of nursing work life which only 39 High 36 45 5 6.25
0.47 0.38
people (48.75%). Low 37 46.25 2 2.5
Total 73 91.25 7 8.75
Table 4. Distribution of Mean, SD, Min-Max, Confident
Interval of QNWLSubvariables
QNWL of Based on table 6 there was most respondents (91.25%)
No Associate Mean SD Min Max 95% CI had low category of WMDs, and it was quite similar
Nurses percentage for they who had high QNWL and low
1 Work 41.08- QNWL. However, respondents who had moderate
42.16 4.87 32 54
Environment 43.25 category of WMDs only 8.75%, which are with high
2 Relationship QNWL (6.25%) and low QNWL (2.5%). In addition, the
19.02-
with Head 19.49 2.08 13 25 results of this study also obtained that there was no
19.95
Nurse relationship between the qualities of nursing work life
3 Work 33.80-
35.11 5.91 21 48 with work-related musculoskeletal disorders, ρ > 0.05.
Condition 36.43
4 Job 48.83-
49.98 5.14 37 60 Discussion
Perception 51.12
5 Support 19.63-
20.15 2.32 15 26
Service 20.67 Associate Nurses Characteristics
166.8 163.21- The mean of respondents’ age was 34 years old. This
Total 16.5 130 198
9 170.56
result is the same as Saftarina and Simanjuntak’s research
(2017) at Abdul Moeloek General Hospital, the number
of nurses aged ≥ 34 years old (53.5%) was more than
In table 4, the job perception sub-variable had a higher who those aged < 34 years old12. In this study, the
mean value (49.98), with variation of the value of 5.14. respondents were clinical nurses at the N3 level who have
The lowest score was 37 and the highest score was 60, at least 10 years of work. The level of N3 nurse is the
which means that Job Perception was the most influential career level of nurse with advanced level (competent),
component in improving the quality of nursing work life who are clinically given authority in accordance with the
for associate nurses. Furthermore, Relationship with head competencies that have been possessed through nurse
nurse subvariable was the lowest mean (19.49%), which competency tests.
mean that a less harmonious relationship between the
associate nurses and the head nurse contributed to the low The number of female nurses more than male nurses as
quality of nursing work life of associate nurse. same as the number of nurses at the hospital is mostly
female. As with Samtica's (2011) study at another general
Worked-Related Musculoskeletal Disorders (WMDs) hospital, the ratio between female nurses was greater than
of Associate Nurses male nurses13. Based on marital status, the number of
nurses who were married (93.8%) more than those who
Table 5. Frequency Distribution and Pecentages of WMDs were not married did. This was related to the average age
of Associate Nurses (N=80)
of nurses in young adults who got married.
Worked-Related
n %
Musculoskeletal Disorders The majority of associate nurses have an ideal body
Low 73 91.3 weight. This result was similar study of with Chanchai, et
Moderate 7 8.8 al. (2016) that found the average of body weight of Thai
High 0 0 nurses was normal with a mean value of 24.914. They
Very High 0 0 may have physical activity at their unit ward and may

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have the high understanding about healthy patterns and
lifestyles.
The length work of nurses in the hospital was contrastly
to the lenght work of nurses placement in the unit ward.
The length work of nurses in hospital was slightly more
10 years, while the length work of nurses placement in
the unit ward was less than 10 years. The mutation
system at the hospital induced the respondent had less
length time in new unit. Majority of them was mutated
from psychiatric care unit.
The number of nurses who had no musculoskeletal
disorders before working at the unit was fewer than those
who had musculoskeletal disorders after working in the
unit. This might be induced the greater workload both
physically and psychosocial in the present unit than in the
previous unit. The majority of associate nurses assumed
that the cause of musculoskeletal disorders was due to
direct nursing care to clients such as transferring and
lifting clients, which mean that nursing implementations
had a high risk of musculoskeletal disorders. Nursing
implementations was related to manual handling and
ergonomic posture while nurses were doing nursing care.
The majority of respondents who had musculoskeletal
disorders had low back pain. This strengthened that
manual handling and ergonomic posture had a
contribution to increase the work-related musculoskeletal
disorders.
Quality of Nursing Work Life of Associate Nurses
The study result showed that nurses who have high
quality of nursing work life was more than nurses who
have low quality of nursing work life, although it was
only 2.5% difference. This result is similar an
investigation in Iranian hospitals that among of 112
respondents, 56.7% had high quality of nursing work life
scores and 43.3% had low quality of nursing work life
scores15. This may be due to good physical and
psychosocial work environment, and also supported by
adequate facilities and infrastuctures.
According to subvariabel of the quality of nursing work
life, work environment was quite high (47.5%). It can be
concluded that the work environment in general service
of this hospital study had a good working atmosphere and
had high motivation. There was adequate training
program that can improve the competence and nurse
skills and improve interpersonal relationships between
employees. A good work environment deals with the safe
work both physically and psychosocially, comfortably
working, communications within the team work were
well established, and whether applicable rules can ensure
and facilitate nurses in providing nursing care or not 16. It
is been also revealed that smost nurses felt that their work
environment was not safe either physically, emotionally,
or verbally17.
The relationship with the head nurse, the subvariabel of
the quality of nursing work life, was good. It was
International Nursing Student Symposium and Festival 2018
UI Proceedings on Health and Medicine Vol. 4 2019
evidenced by the number of nurses who agreed that the
relationship between the head nurse and the nurse was
very good, and communication was well-established
(48.8%). This was showed that every new change directly
informed by head nurse to the associate nurses. Effective
communication positively contributes to relationships
between leaders and employees17.
According to work Conditions subvariable, most of the
associate nurses were quite satisfied with the payroll and
remuneration policies, as they were deemed to be in
accordance with job responsibilities, workload, and
performance. The factors that influence work conditions
include long working hours, the ability of nurses to
balance between conditions at home and at work, work
which was not related to nursing, and salaries that were in
accordance to workload16. More than 80% of nurses were
unhappy with hours of work that were not in accordance
with their daily living17.
For the job perception subvariables, 56.3% of nurses felt
safe, comfortable, and happy with their work, free to
express opinions related to work that could improve their
performance. Perceptions of nursing jobs will have a
significant impact on improving the quality of nursing
work life. Nurse autonomy in deciding what actions will
be given to patients, problem solving and participatory
decision making has an influence on the quality of
occupational health. Job perception affected the level of
quality of nursing work life of associate nurses 16,17,18.
Support service was the lowest score among the other
five subvariables of QNWL. It is been found that the
intended supporters service were facilities and
infrastructure, one of which was a support system from
other teams (such as medical teams, nutritionist, cleaning
service, administration, etc.) that can help nurses in
providing nursing care to achieve the maximum goal
result19. Supporters Service were also associated with
harmonious relationships, mutual feelings, and good
cooperation with co-workers. From the results of this
study, supporters service in the hospital still need to be
improved.
In addition, each sub-variable had a relationship with
each other in determining the level of QNWL of associate
nurses. Based on the results of the study, it can be
concluded that the work environment, the relationship
with the head nurse, the work conditions, and the job
perception at the hospital were conducive, safe, and
pleasant, even though support services were still not
optimal.
Worked-Related Musculoskeletal Disorders
This study found seventy associate nurses had lower
category of worked-related musculoskeletal disorders
experience. MMDs experienced by nurses due to
repetitive work of high workload, and work positions that
not match to ergonomics. It means that the work position
exceeds the physical ability of the nurse itself such as a
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long bending position, lifting a client who has bigger
BMI than the nurse, and pulling a heavy load.
In this study, there were 57.5 % respondents realized the
cause of musculoskeletal disorders was due to work.
These results were consistent with a study in Fatmawati
Hospital that associate nurses, especially whose working
at Emergency unit, have a high risk of musculoskeletal
disorders4. Nurse activities developing risk of WMDs
were when the nurse’s position mostly bent such as
lifting and moving clients, doing wound care, checking
the vital signs of the client, placing an infusion, giving an
intravenous injections, and delivering basic human needs
(bathing, helping client mobilization, providing a
comfortable position).
WMDs were influenced by many factors, for example in
terms of characteristics of associate nurse. Based on
gender, female nurses had a 2.26 times higher risk than
male nurses3. This was related to female's physical ability
which is lower than male. Married women had 1.69
higher risks of musculoskeletal disorders than married
man. This was due to the role of housewives that had a
fairly high activity, such as caring for children, cooking,
and cleaning the house, and having the workload during
the hospital.
Nurses who had high BMI had a high risk of developing
musculoskeletal disorders7. In this study, nurses in the
hospital had a low risk of musculoskeletal disorders,
because most nurses had a normal BMI. This study
showed that WMDs experienced by respondents were in
low and moderate categories.
Relationship of Quality of Nursing Work Life and
Work-Related Musculoskeletal Disorders of Associate
Nurses
The results of this study proved that there was no
correlation between the qualities of nursing work life of
associate nurses with work-related musculoskeletal
disorder. The quality of nursing work life of nurses who
had low musculoskeletal disorders category was almost
the same as nurses who have moderate categories. This
result was inversely proportional to previous research
which stated that the quality of nursing work life was a
psychosocial factor that had a significant relationship
with musculoskeletal disorders8. This may be due to the
quality of nursing work life of nurses; especially the sub
variables of the work environment and the job perception
scores were higher than the scores of other sub variables.
A safe and comfortable environment will reduce the risk
of musculoskeletal disorders. Conversely, if the work
environment is dangerous, such as slippery floors and
less room lighting, it will certainly increase the risk of
musculoskeletal disorders. In addition musculoskeletal
disorders are more influenced by manual handling factors
and work positions were not ergonomic. This study found
that before working in that unit, most of nurses did not
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UI Proceedings on Health and Medicine Vol. 4 2019
have musculoskeletal disorders, but after work in that
unit, work-related musculoskeletal disorder was occurred.
Furthermore, the most common types of musculoskeletal
disorders were low back pain.
The results of this study can be confirmed that the quality
of nursing work life of associate nurses was more
influenced by psychosocial factors than by physical
factors. For example, based on the characteristics of
nurses, although there were differences in age but do not
affect the quality of nursing work life
Conclusion
The more than half associate nurses had a high quality of
nursing work life and the majority of associate nurses had
low WMDs. There was no relationship between the
qualities of nursing work life of associate nurses with
WMDs. This means that although the nurse has
musculoskeletal disorders, the quality of work life
remains high. Although some nurses do not had WMDs,
but some of them have a low quality of nursing work life.
The relationship between the head nurse and associate
nurse still needs improvement, both in terms of
communication, information, balance between reward
and punishment, and psychosocial support. Supporting
services still need to be improved both in the form of
facilities and infrastructure. In addition, standard
operating procedures (SPO) related manual handling and
posture ergonomic when performing nursing
implementations is necessary as an effort to prevent
WMDs. Continuing education and training for nurses are
also very necessary to improve nurses work safety. For
future study, it is needed to evaluate this with larger
number of respondents from multicenter research setting.
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