INTRODUCTION
Nursing staff provides patient care in an occupational environment that often imposes challenges that affect significantly the musculoskeletal system. The specific requirements of nursing duties will be analyzed in relation to the different types of musculoskeletal disorders (MSDs). The role of the different factors that are related to the prevalence of these disorders will be emphasized to elucidate the impact on working ability and quality of life (QoL) of nursing staff, and to propose preventive measures.
NURSING STAFF: DUTIES AND SHIFTS
The main body of nursing staff types typically includes registered nurses (RNs), licensed practical nurses or licensed vocational nurses, and advanced practice RNs (APRNs). These categories represent different levels of education, training, and scope of practice within the nursing profession. RNs are licensed healthcare professionals who have completed a nursing program (typically an associate or bachelor’s degree in nursing) and have passed the respective exam. They provide direct patient care, including assessing patients’ health, developing care plans, administering medications, and educating patients and their families. Licensed practical nurses or licensed vocational nurses are licensed nurses who have completed a practical nursing program (usually a diploma or certificate program) and have passed the respective exam. They work under the supervision of RNs or physicians and provide basic nursing care, such as taking vital signs, dressing wounds, and administering medication. APRNs are RNs who have obtained additional education and training at the graduate level. APRNs have advanced clinical skills and are authorized to diagnose and treat patients, prescribe medications, and provide primary or specialty care in various healthcare settings. While these three categories encompass the majority of nursing roles, there are also other specialized nursing roles and certifications within each category, as well as variations in nursing practice based on factors such as geographic location, healthcare setting, and specific patient populations served.
Concerning the nursing shifts these include day shifts typically occurring during daytime hours (7:00 AM to 7:00 PM or 7:00 AM to 3:00 PM), evening shifts (3:00 PM to 11:00 PM) and night shifts, typically occur during nighttime hours (7:00 PM to 7:00 AM or 11:00 PM to 7:00 AM). Each type of shift has its own unique characteristics, and nurses may have preferences based on their personal and professional needs. Moreover, factors such as staffing levels, patient acuity, and organizational policies may influence the availability and scheduling of nursing shifts within specific healthcare facilities. Nurses working day shifts have more predictable schedules and may have more opportunities for interaction with patients, families, and other healthcare team members, while those working night shifts may experience disruptions to their sleep patterns and may face challenges with fatigue and maintaining alertness. Finally, nurses working evening shifts may have more flexibility with their schedules compared to day or night shifts. Rotating shifts involve working a combination of day, evening, and night shifts on a rotating basis, often predetermined. Nurses working rotating shifts may experience challenges with adjusting to different sleep schedules and maintaining work-life balance. Weekend shifts typically occur on Saturdays and Sundays, and may involve working either 8-hour or 12-hour shifts. Nurses working weekend shifts may have fewer staff members and resources available compared to weekdays. However, weekend shifts may offer additional compensation or scheduling flexibility for nurses who prefer to have weekdays off. Pro re nata shifts are as-needed shifts, where nurses may work on a temporary or occasional basis to fill staffing gaps.
TYPES OF MSDs
MSDs include injuries and pathological conditions of muscles, tendons, bones and joints, nerves and vessels that result in problems concerning the shape, support, stability and movement of the body. Many studies underlined the prevalence of lower back, shoulder, and ankle-feet symptoms in nursing staff. Sun et al[1] conducted a meta-analysis that consolidated the prevalence rates of work-related MSDs at various anatomical sites among nurses, across different countries. According to this meta-analysis the annual prevalence of work-related MSDs was 77.2%, and the anatomical sites with the highest prevalence of these disorders were the lower back, the neck and the shoulder.
FACTORS PREDISPOSING TO MSDs
Factors related to professional tasks and ergonomics
The occupational environment for nurses presents a variety of physical challenges that significantly impact their health and well-being. These challenges arise from a range of demanding tasks inherent to nursing duties, including lifting patients, moving heavy objects, maneuvering machinery, and executing motions that involve extreme postures. Heavy lifting and manual handling can increase the risk of back problems and other MSDs if proper lifting techniques and equipment are not used[2-4]. Furthermore, studies show that engaging in repetitive tasks, such as handling surgical sets and dealing with patients by moving, lifting, or lowering them, as well as pushing or pulling heavy loads, contributes to the escalation of musculoskeletal symptoms[5]. Prolonged standing or sitting, and assuming awkward or sustained postures during patient care activities, such as bending, twisting, or reaching, can place excessive strain on the musculoskeletal system and contribute to respective disorders[4]. The predominant activities observed include repetitive elbow flexion/extension, followed by repetitive movements of the wrist and fingers, and heavy lifting[6], while increased physical demands and workload due to understaffing lead to fatigue and increased risk of MSDs[7].
Another crucial factor is the type of department the nursing staff serves as well as the ergonomic factors. Concerning the department, surgical department and operating room nurses are the most vulnerable[3-5,8]. Positioning patients on the operating table, lifting and carrying instrument trays, organizing instrumentation, maintaining prolonged static postures while assisting surgeons in combination to the “sitting/standing policy” seriously burden the operating room nurses. Additionally, imperfect workspace design and poor maintenance of surgical carts and trays increases the likelihood of musculoskeletal symptoms, while the effect of time pressure on the musculoskeletal system is also underlined is different studies[3,4]. Finally, lack of training and education of nursing staff on prevention of MSDs can result in use of improper techniques that are opposed to ergonomic principles, ineffective use of equipment, and avoidance of self-care practices[9].
Factors related to working schedules
Irregular work schedules, extended shift schedules, night shifts, and rotating shifts can disrupt circadian rhythms, increase fatigue, and impair recovery, potentially contributing to MSDs among nursing staff[5,9]. Several studies showed that the prevalence of low back symptoms was significantly higher among shift or night workers compared to day workers[10,11].
Psychological and social factors
The correlation between psychological/social factors and MSDs is significant. Stress related to the specific professional environment including high patient volumes, time pressure and feeling of lack of control in combination to fatigue from specific manual tasks gradually burden the health of nursing staff. In addition, the effort-reward imbalance and the low respect are key factors leading to disorders of the musculoskeletal system[7,12,13]. There is also an important link between MSDs and somatic stress symptoms, including headache, muscle tension, and palpitations, while burnout is associated with increased risk of MSDs among nursing staff[14].
A frequently underestimated psychological factor related to MSDs and low back pain in nursing staff is kinesiophobia, which is a pain-related fear of movement/reinjury. This can cause a vicious cycle leading to physical inactivity which negatively affects recovery and relief from musculoskeletal pain and subsequently of QoL[15]. A critical factor affecting the wellbeing of nurses is the presence of depression. Studies show that comorbidity of MSDs and depression is prevalent among hospital nurses, which is worrying for both nurses’ health and patient care[16,17]. Furthermore, sleeping disorders, especially insomnia, are associated with a higher risk of chronic musculoskeletal pain including low back pain[18]. Finally, the role of conflicts must be emphasized. Work-family conflict is a common type of role conflict between occupational and family demands. The association between work-family conflicts and MSDs has been underlined in several studies[14,16].
Individual factors
Age, gender, and body mass index are important factors affecting the likelihood of developing musculoskeletal symptoms in nursing staff, while daily exercise also has a distinct effect. Increasing age is associated with decreased muscle strength and flexibility, with decreased bone density and with increased rates of MSDs[19,20]. Abdollahzade et al[21] demonstrated an important relationship between working postures and age. Female gender is also correlated to working postures, as women are predisposed to uncomfortable postures, which leads to musculoskeletal symptoms[21]. Another notable individual factor for the development of musculoskeletal symptoms is body mass index: Being underweight is a recognized risk factor[5]. Finally, the effect of daily exercise on ergonomic postures is underlined in a recent study[21].
IMPACT ON WORKING ABILITY AND QoL
MSDs pose significant challenges to the working ability and QoL of nursing staff. Limitation in working ability due to MSDs include reduced mobility, limitations in lifting and transferring patients, limitations in equipment handling, avoidance of repetitive tasks, and restricted working hours. Thus, MSDs may lead to decreased productivity at work due to health issues (presenteeism) or to absence from work (absenteeism)[22-24]. Both presenteeism and absenteeism have an impact on the workflow and on the quality of patient care, while the presence at work despite the MSDs amplifies vulnerability of the nursing staff and may limit career advancement opportunities and professional development, causing career dissatisfaction or even to the desire to leave the profession[24-27].
Concerning the QoL, MSDs affect negatively almost every aspect of nurses’ QoL. According to a recent study, the more the musculoskeletal symptoms and the sites affected, the greater the deterioration in QoL[28]. MSDs affect physical and mental health and influence the work-life balance. Physical discomfort and pain reduce the ability and functionality with a direct effect on daily activities and hobbies apart of the effect on professional performance. Dealing with chronic pain and physical limitations can have an adverse effect on nurses’ emotional well-being, that can lead to increased stress, anxiety, or depression. In addition, musculoskeletal pain is a significant risk factor for insomnia[29]. Inadequate sleep leads to a vicious cycle where fatigue and exhaustion can exacerbate physical symptoms and emotional distress, further impacting the overall QoL.
Finally, the financial impact of ongoing musculoskeletal pain can be substantial for individuals and their families, affecting their personal and social welfare. Difficulty in sustaining regular employment, increased absenteeism due to illness, and reduced activity levels contribute to financial strain related to musculoskeletal pain and disorders[30].
PREVENTION
Preventing MSDs in nurses requires a multifaceted approach that addresses individual, ergonomic and organizational factors. The risk of developing MSDs can be reduced through knowledge and application of ergonomic principles by nursing staff. Working under appropriate ergonomic conditions can increase nurses’ motivation and job satisfaction while diminishing job stress, absenteeism, occupational diseases, and work-related accident[9,31].
Another beneficial prevention measure is use of assistive devices and lift teams that familiar with lifting techniques. It is well documented that patient handling can be conducted safely through usage of assistive equipment and devices, effectively eliminating hazards that can lead to MSDs. The implementation of assistive patient handling equipment not only reduces the risk of musculoskeletal injuries for nursing staff but also enhances the quality of care provided to patients[32]. Nurses’ education and awareness play a crucial role in restricting MSDs by promoting proper techniques, identifying risk factors, encouraging self-care practices and facilitating early intervention. Prevention and prompt detection of MSDs averts progression to chronic and more serious diseases[31,33,34].
Finally, corrective exercise training involves the implementation of specific exercises and movements designed to address muscular imbalances, postural issues, and other biomechanical problems within the body. Exercise intervention is considered effective on controlling musculoskeletal symptoms in nursing staff. Safaeian et al[35] compared corrective exercise and ergonomic training, concluding that both are important, but corrective exercise training is more effective in reducing low back pain. Therefore, managers could devise exercise strategies tailored to address various musculoskeletal symptoms[36].
CONCLUSION
MSDs pose a significant challenge to the nursing profession, affecting both the physical well-being and professional performance of nursing staff. The combination of physically demanding tasks, irregular work schedules, and psychological stress creates a high-risk environment for the development of these disorders. As the prevalence of MSDs in nursing staff is alarmingly high, especially affecting the lower back, neck, and shoulder, it becomes clear that proactive measures must be taken to mitigate these risks. Ensuring proper ergonomic practices, providing education on safe patient handling techniques, and offering access to assistive devices can reduce the strain on nurses’ musculoskeletal system. Additionally, fostering a supportive work environment that promotes regular exercise, healthy work-life balance, and addresses psychological stressors is crucial for improving nurses’ overall QoL and work ability. By prioritizing the prevention and management of MSDs, healthcare organizations can enhance not only the health and well-being of their nursing staff but also the quality of patient care provided.
Provenance and peer review: Invited article; Externally peer reviewed.
Peer-review model: Single blind
Corresponding Author’s Membership in Professional Societies: American Academy of Orthopaedic Surgeons, 216303.
Specialty type: Orthopedics
Country of origin: Greece
Peer-review report’s classification
Scientific Quality: Grade C
Novelty: Grade B
Creativity or Innovation: Grade B
Scientific Significance: Grade B
P-Reviewer: Musat EC S-Editor: Wei YF L-Editor: A P-Editor: Zhang L
