Carla Sílvia Fernandes1; Germano Couto1,2; Rogério Carvalho2,3; Daniela Fernandes2; Patricia Ferreira2
BACKGROUND: Work-related musculoskeletal disorders (WMSDs) are responsible for morbidity among many health professionals.
OBJECTIVE: To establish the prevalence of self-reported WMSDs among health professionals
METHODS: Descriptive and exploratory study with health professionals at a hospital in northern Portugal. Data were collected in December 2017 by means of an electronic questionnaire applied to the total target population (n=435). We applied instruments for sociodemographic characterization, perception of knowledge on ergonomics and manual mobilization of loads, the Patient Handling Burden Scale (PHBS) and the Nordic Musculoskeletal Questionnaire (NMQ) for self-reporting musculoskeletal symptoms.
RESULTS: The sample comprised 105 professionals, mainly nurses and nursing assistants, who exhibited high frequency of symptoms in several body areas, mainly the spine.
CONCLUSIONS: WMSDs involving health professionals should be considered a problem for health institutions which do not implement interventions beyond traditional training programs, especially multifactorial programs of systemic nature.
Keywords: working conditions; occupational risks; occupational health; allied health personnel; musculoskeletal diseases.
INTRODUÇÃO: Os distúrbios osteomusculares relacionados com o trabalho (DORT) são responsáveis pela morbidade de muitos profissionais de saúde.
OBJETIVO: Realizar um diagnóstico da prevalência de DORT autorreferidos por profissionais de saúde.
MÉTODOS: Foi realizado um estudo, descritivo e exploratório, envolvendo profissionais de saúde de uma instituição hospitalar no norte de Portugal. Os dados foram coletados ao longo do mês de dezembro de 2017, mediante aplicação de questionário eletrônico à população total (n=435). Foram utilizados instrumentos de caracterização sociodemográfica, percepção de conhecimentos sobre ergonomia e mobilização manual de cargas, avaliação da percepção de carga (Escala de Percepção de Carga de Manuseio do Paciente — EPCMP) e sintomas osteomusculares autorreferidos (Questionário Nórdico de Sintomas Osteomusculares — QNSO).
RESULTADOS: A amostra foi constituída de 105 profissionais, essencialmente enfermeiros e assistentes operacionais, apresentando uma ocorrência elevada de sintomas em diversas regiões corporais, maioritariamente na coluna vertebral.
CONCLUSÕES: DORT em profissionais de saúde devem ser considerados um problema nas instituições de saúde que carecem de intervenções além dos tradicionais programas formativos, especialmente programas multifatoriais de natureza sistémica.
Palavras-chave: condições de trabalho; riscos ocupacionais; saúde do trabalhador; pessoal técnico de saúde; doenças musculoesqueléticas.
Activities involving manual handling of loads might result in a wide range of musculoskeletal disorders. Work-related musculoskeletal disorders (WMSDs) represent a significant burden for society at large, organizations and the workers themselves. The reason is that these conditions affect the working population, and contribute to increase absenteeism and decrease productivity and the quality of life of workers1. Health professionals suffer musculoskeletal injuries more frequently than other professional groups2. They constitute a vulnerable group, with 4 times higher risk than workers in the industrial sector3,4.
In their review of 27 studies, Anderson and Oakman predicted that most health professionals will experience WMSDs throughout their careers. As risk factors they identified being young, having less years of experience and being exposed to high levels of manual and repetitive tasks5.
The tasks performed by health professionals involve exposure to a variety of risk factors that might contribute to the onset and development of WMSDs6. A recent review established causal relationship between the mechanical stress caused by tasks related with patient treatment and development of WMSDs7. Tasks requiring awkward joint positions or hand/finger force application or which pose strain to the spine, especially the lower back, are risk factors for development of WMSDs8-11. Within the overall context of health care, and in the specific case of hospitals, handling patients is highly frequent and involves complex tasks with impact on and which cause overload to the musculoskeletal system6,12-14. Other daily patient care tasks with impact on the physical overload are related to hygiene, treatment and feeding, among others7,15. These tasks involve exposure to occupational risk factors due to high biomechanical and physiological demands that exceed the functional capacity of workers in organizations that do not afford adequate recovery and rest times6,8.
WMSDs affect different parts of the body, such as the shoulders, neck, elbows, hands, wrists, knees and spine5. These are chronic pain syndromes which occur during the performance of definite job tasks, for which reason are called ““work-related”8,9,16. WMSDs of the upper limbs often occur under certain working conditions, such as activities which involve repetitive tasks5,16. However, the most frequent complaints with impact on work correspond to the spine, particularly the low back area5,16,17. Low back pain is a major occupational problem among health professionals. An expensive occupational health problem, it is one of the main causes of disability-related absenteeism directly and is influenced by work-related factors18,19.
Given the need to prevent WMSDs and the immutability of the work situation, the focus falls on the implementation of training programs on patient handling techniques for health professionals6,20-22. As Anderson and Oakman observed, the high prevalence rates found point to a need for more effective risk reduction interventions and contribute to reinforce the complex multifactorial nature of WMSD development5.
Considering the need to intervene at this level, and as the first step in the implementation of a multifactorial program to reduce WMSDs, establishing a diagnosis to analyze the prevalence of these lesions is crucial, and was the aim of the present study.
Anderson and Oakman stated that the self-reported prevalence of WMSD rates differs from injury reports, and stressed the relevance of consistent and valid data5,23. This observation agrees with the aim of the present study, which was to investigate the occurrence of symptoms (mainly discomfort and pain) among all the professionals at a hospital in northern Portugal.
The aim of the present descriptive and exploratory study was to investigate musculoskeletal symptoms reported by health professionals at a hospital in northern Portugal (Fernando Pessoa Teaching Hospital). Self-reported measures of musculoskeletal discomfort are widely used for diagnosis of musculoskeletal disorders1,3,4,6,7,9,11,12,22.
The questionnaire applied to the participants was divided into four main sections:
sociodemographic characteristics, e.g., sex, age, body weight, height and professional category;
knowledge about ergonomics and manual handling of loads;
resource assessment and environmental issues;
self-reported musculoskeletal symptoms in nine body areas (neck, dorsal, lumbar, shoulders, elbows, wrists / hands, hips / thighs, knees and ankles / feet).
An adaptation of the Nordic Musculoskeletal Questionnaire (NMQ)24 was used to investigate self-reported musculoskeletal symptoms. This version is widely used in Portugal and has been previously tested for reliability and validity25. The main objective of NMQ is to develop a method of epidemiological study through a set of standardized questions to identify musculoskeletal complaints or symptoms among different professional groups6,9,12,22,25. It has also been widely used to investigate presence of work-related musculoskeletal symptoms1,3,4,12,22,25. The instrument includes a posterior view of a human figure divided into nine anatomical areas. It comprises questions on presence of musculoskeletal pain in the past 12 months and past 7 days, and functional disability in each of the nine areas26.
To investigate the perception of load, we used the Patient Handling Burden Scale (PHBS). This is a self-report questionnaire developed by Graça et al. and validated for the Portuguese population27. The questions, responded on a Likert scale, investigate effort in patient transfer, degree of pain felt and time spent in transfers.
To cover the total target population (n=435) a link to the study questionnaire was sent to all the professionals in the institution by e-mail. Sampling was non-probabilistic as it resulted from voluntary participation (n=105). The confidentiality of the data and participant anonymity were ensured all throughout data collection. The study was approved by the institutional board and ethics committee. Statistical analysis of the results was performed with Statistical Package for Social Sciences (SPSS 18®).
The sample comprised 105 health professionals, representing 24.1% of the total population. Most participants were female (80%), right-handed (96.2%) and aged 19 to 63 years old, mean 33.7. While most participants were nurses (38.1%) and nursing assistants (25.7%) the sample also included secretaries, physicians, physical therapists, psychologists and speech therapists (Table 1).
As to their educational level, the participants had attended graduate education (47.6%), secondary school (33.3%), master (13.3%) and doctoral (2.9%) programs. About 39% were single, 37.1% married, 11.4% lived with a partner, 8.6% were separated and 3.8% were divorced. The average time in the profession ranged from 0 to 34 years, mean 5.7 years. Most participants were allocated to inpatient services (40%). The working time was 40 hours per week for the vast majority of the sample (91.4%) and the largest proportion performed shift work, including night shift (42.9%). Among 45.7% of participants who reported practice physical exercise, frequency was once per week for 31.3%, twice per week for 33.3%, and 3 times per week for 29.2%; the most frequent modality was gymnastics,17,1%. The body mass index fell within the normal range for the majority of the sample (69.5%).
Regarding the participants’ opinion on the institutional resources to prevent WMSDs, 16.2% stated the environment was inadequate, 21.9% that they did not have the necessary resources, 21.9% that professional allocation was inadequate, and 24.7% that the institution did not provide adequate training for prevention of WMSDs. Relative to the participants’ self-assessed knowledge and skills to prevent WMSDs, 16.2% stated the raining curriculum did not include ergonomics, 7.6% that they had no knowledge on how to handle people or loads, 34% that their lack of knowledge had already interfered with their handling of people or loads, and 31.5% lack of skills in this regard.
Analysis of the PHBS dimensions (Table 2) relative to perception of last transfer performed showed that 80% of the sample reported to have needed effort, 56.2% occurrence of pain, and 55.2% excessive time spent in this procedure.
Participants reported high frequency of WMSD symptoms, as shown in Table 3. For some body sites, the frequency of reported pain in the past 12 months was higher than 40%. The following sites stood out: lower back (76.2%), neck (59%), right shoulder (52.4%) and dorsal area (47.6%).
The frequency of symptoms in the past 7 days, probably more authentic due to their proximity with the report of complaints, was lower: lower back, 37.1%; neck, 24.8%; and right shoulder and dorsal area, 17.1%. Difficulties in activities of daily living (work-related, household chores, hobbies) were noteworthy, especially for symptoms on the lower back (29.5%), neck (18.1%), right shoulder (23.8%) and dorsal area (19.0%).
The results also showed association between prevalence of pain in different locations and individual characteristics, such as sex, work schedule, academic qualifications, physical exercise, time in the job and workload (Table 4).
High rates of work-related complaints among health professionals — nurses, physical therapists and physicians — are well documented in the literature4,5,9,15,19. The global morbidity associated with WMSD involving the lower back is estimated as 0.8 million disability-adjusted life years (DALY) and represents the main cause of absenteeism. Health professionals are a group vulnerable to these conditions, particularly the ones whose work involves mobilizing patients on a daily basis6,15,19. The vast majority of studies on health care delivery performed surveys using self-report questionnaires, especially the Nordic Musculoskeletal Questionnaire (NQM)5,6, as it provides precise metrics for the purpose of comparison. According to Anderson and Oakman, surveys which consider consistent outcome measures are necessary to improve the possibility of meaningful comparisons between studies5.
Among the main results of our study, we call the attention to the fact that the sample mainly comprised nurses and nursing assistants. As widely shown in the literature, nurses are a frequent target of this type of research3,6,12,13,19. Health professionals, such as nurses, are exposed to substantial work overload, as their tasks involve physically demanding effort and exposure to a several psychosocial hazards5,18,19. The prevalence of injury is higher at hospitals compared to other healthcare settings18. Currently, health professionals deliver care in facilities characterized by high technological, instrumental and physical complexity, and are exposed to continuous time pressure and to tension associated with the delivery of high-quality care6.
The participants in the present study were essentially female (80%) which agrees with the results of other studies5,14,17,19. Their average age was 33.8 year old, which let us infer that the average population was within the risk age range, i.e., 30 and 55 years old26.
In their review article, Anderson and Oakman suggest that the prevalence of self-reported WMSD might be exposed to low memory bias. However, in all 27 included studies the rates of self-reported complaints differed from the ones of injury reports. This finding points to inconsistency of the data, which thus might not reflect the true magnitude of the problem5.
Occurrence of symptoms was frequent in several body sites, mainly in the spine and lower back, thus agreeing with the results of other studies9,12,17,19,26. As is known, activities related to patient handling and transport place considerable demands to the spine and require inappropriate postures6. Analysis of occurrence of pain per professional category showed that low back complaints were reported by 75% of nurses, 92% of nursing assistants and 76.6% of secretaries. The physicians’ complaints most frequently involved the neck (66.6%).
Poor body mechanics and lack of training on load handling techniques are considered to be the main causes of the high prevalence of low back pain18, which justifies the need for interventions at this level. The relevance of such interventions is supported by the participants’ assessment of the institutional resources, namely the training provided, as well as of their knowledge and skills. Analysis of the PHBS results indicated that transfers always involve physical overload.
The collected data meet the main aim of the present study and enable the implementation of the first stage of a multifactorial program to reduce WMSDs through diagnosis of the prevalence of these lesions among the study population.
In view of the need to prevent WMSDs, research focused on the implementation of training programs on patient handling techniques for health professionals6. However, in the systematic review performed by Clemes et al. to evaluate evidence on the effectiveness of different approaches to manual load-handling training, the authors did not identify any evidence supporting the effectiveness of manual manipulation training based on techniques and education alone15. In addition, considerable evidence supports the idea that the principles learned during training are not applied in the workplace. Neves & Serranheira also mentioned this fact and stressed the effectiveness of systemic multifactorial programs as opposed to exclusive training in patient handling techniques in terms of risk of WMSDs among health professionals6. The present study is the first stage of a project to be developed at a hospital unit and the subject of future publications.
The sample exhibited high prevalence of WMSDs. The self-reported symptoms involved different body sites and were most frequent on the spine, the lower back in particular. This study provides additional data to the growing evidence for the exposure of health professionals to a variety of risk factors associated with high prevalence of work-related symptoms. Manual mobilization of loads might lead to a wide variety of musculoskeletal disorders, which represent a significant burden to organizations and the professionals themselves. Therefore, strategies to improve the working conditions to prevent their occurrence should be implemented. Accurate knowledge about injuries and establishing preventative measures are crucial for the development of healthier organizations conceived in terms of the people who work at them.
Further research is needed to establish the epidemiology of WMSDs, and also to lend further support to the need to develop occupational preventive and control programs. Multifactorial programs of systemic nature are recommended instead of the exclusive focus on training programs.
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7 de Fevereiro de 2018.
Aceito em 2 de Julho de 2018.
Fonte de financiamento: nenhuma