Effect of training and reminding ergonomic posture on prevention behavior for musculoskeletal disorders in nursing students: A randomized controlled trial study

Abstract

BACKGROUND:

Nursing students are at risk of physical health problems from the beginning of their academic year due to the high workload and, according to previous studies, they often suffer from musculoskeletal disorders (MSDs). To investigate the effect of training and reminding ergonomic posture on MSD prevention behavior in nursing students.

MATERIALS AND METHODS:

The study used a randomized controlled trial. The study was conducted on seventh and eighth-semester nursing students at the Ramsar Nursing School in Iran, from September 2023 to January 2024. Participants in the intervention group received the ergonomic posture training and reminders, while the control group behaved according to their previous routine. Compliance with ergonomic posture behavior was assessed in both groups before and after one month. The data were analyzed using the Statistical Package for Social Sciences (SPSS) version 21.

RESULTS:

The results showed that 10 (37%) males and 17 (63%) females were in the intervention group, and 11 (42.3%) males and 15 (57.7%) females were in the control group. The mean and standard deviation of compliance with MSD prevention behaviors were 154.96 ± 15.85 and 166.77 ± 16.7 in the intervention group before and after the intervention, respectively, and 158.8 ± 15.61 and 159.3 ± 14.6 in the control group before and after the intervention, respectively, and no statistically significant difference was found (P > 0.05).

CONCLUSION:

The results of the study suggest that training and reminding ergonomic posture has no effect on prevention behavior for MSDs in nursing students. Therefore, in future studies, it is better to implement the current intervention over a longer period of time and with a modified type of training and reminding so that the improvement of the effect of the intervention can be observed.

Introduction

Human resources are the most important assets and resources of the healthcare system, and the quality of their performance has a direct impact on the quality of services provided to patients. One of the most important pillars of the healthcare system is nurses, who bear the significant responsibility of providing round-the-clock care to patients in medical centers.[1] Nursing is a profession that carries a heavy workload not only in professional life but also during academic life worldwide.[2] Nursing students are at risk of experiencing physical health problems early in their careers due to this high workload.[3] Nurses in Iran face a heavy workload. The average ratio of nurses to hospital beds in Iran is less than half the global average. This leads to a high workload and burnout among nurses.[4] In addition to the heavy workload, the nature of the nursing profession requires a lot of physical activity, such as frequent bending, twisting, standing for extended periods, moving patients, lifting heavy objects, and not taking adequate rest breaks between tasks.[5,6] Given the consequences of occupational musculoskeletal disorders (MSDs) on a country’s economy and productivity, it is essential to understand the underlying causes of MSDs and effective ways to prevent them.[7] Studies show that MSDs are very costly economically, ranking first in terms of causing pain and suffering to an individual, and among them, low back pain is in the first place.[8,9]

Some research conducted over the past 3 years suggests that psychosocial factors, ergonomic conditions, and mental health are key factors that can influence individuals’ experiences of education.[10]

Studies have been conducted to improve the educational quality of internships in clinical disciplines such as nursing and medicine. However, few studies have been conducted in the field of posture assessment and ergonomic behavior assessment in Iran.[11,12]

In general, MSDs have a multifactorial origin with physical, psychological, and social causes. Physical causes may include poor posture, repetitive movements, excessive force during the workday, and an unfavorable work environment. Studies have shown that a mismatch between people and the workplace can lead to pain in the legs, feet, knees, neck, shoulders, and back.[13]

Nursing students are the future of the profession, and what they experience during their studies is crucial to their future careers. This is especially significant in the final semesters of students who work exclusively in hospitals.[14]

Previous studies illustrate that nursing has one of the highest rates of MSDs.[15] The most common MSDs in nursing include back pain, neck problems, shoulder pain, arm, wrist, and knee injuries.[16]

A systematic review of the prevalence of MSDs in nursing in 2018 showed that the prevalence ranged from 33.0% to 88.0%. The most affected body regions were the back, shoulder, neck, knee, and wrist/hand, with back pain complaints ranging from 49.0% to 84.0%.[17]

In the same year, a systematic review was conducted in Iran with the same aim as the above study. According to the results, the prevalence of MSDs was 60.98%, 47.76%, 46.53%, 44.64%, 42.8%, 36.8%, 24.61%, and 17.5% in the back, neck, knee, upper back, ankle, shoulders and hands, hips, thighs, and elbows, respectively.[18] Many studies dealing with MSDs in nurses cite the failure to consider ergonomics in the work environment as the main cause of these problems.[19] Ergonomics is the science that studies people in relation to their work environment. It is a science that deals with the general and effective relationship between man, tool, and environment and seeks to maximize productivity for the evolutionary goals of the work category in today’s complex technology system by understanding the interaction of these three factors.

Ergonomic position is a position that must be observed when working and performing various activities to increase work safety and efficiency and reduce risk factors. Ergonomic posture actually refers to the correct positioning of the body while working in various positions and tasks, such as sitting, standing, lifting equipment, the way the neck, shoulders, and back are positioned, and the like.[20,21]

Maintaining proper ergonomic posture is crucial for nursing students to prevent MSDs because nursing students are potential nurses, and knowing the proper ergonomic posture while working can be the future of their correct behavior in this field. However, this issue is often overlooked in nursing courses in Iran, leading to students not observing proper ergonomic posture during work, which can result in MSDs.[22]

A study represented that over 50% of students maintain incorrect body positions during nursing interventions.[23] Given the high rate of MSDs in nursing students and the limited studies on ergonomic status in this population, the aim of this study was to investigate the effect of training and reminding ergonomic posture on MSD prevention behaviors in nursing students.

Materials and Methods

Study design and setting

The study used a randomized controlled trial and was conducted on seventh and eighth-semester nursing students at the Ramsar Nursing School in Iran, from September 2023 to January 2024.

Study participants and sampling

The statistical population of this experimental study was all seventh and eighth-semester nursing students at the Ramsar Nursing School in Iran. First, the researcher compiled a list of hospital groups that consisted of seventh and eighth-semester nursing students who actively participated in the internships on all days of the week. These groups were divided into 10 groups of six students each and then randomly assigned to two intervention and control groups using random numbers. Thereafter, 60 eligible individuals (30 in the control group and 30 in the intervention group) were included in the study. Seven of them dropped out during the study, resulting in a final number of 53 study participants (26 in the control group and 27 in the intervention group) [Figure 1].

Figure 1.

Flowchart of the study design

The inclusion criteria for the sample included a willingness to participate in the study, being in the seventh or eighth semester of nursing, no self-reported history of MSDs, no musculoskeletal surgeries in the last 6 months, having a smartphone and internet connection, and no previous experience with ergonomic workshops or courses. The exclusion criteria involved unwillingness to continue participating and missing the daily reminders for more than three days a month.

Data analysis

The study procedure for the intervention group involved completing all questionnaires at the beginning of the study. Subsequently, depending on the students’ availability, two training sessions on postural ergonomics were conducted by an ergonomics specialist in one of the classes at the Faculty of Nursing, along with providing a brochure with information about the workshop. The workshop began with presenting the research objectives and teaching material. It then covered the correct posture of the head, neck, shoulders, hands, back, and legs, as well as correct standing, sitting, and the correct use of equipment when working in nursing.

At the end of the second session, each student individually demonstrated the correct postures taught, and a photo was taken of each student in the correct ergonomic posture. In the subsequent ergonomic posture reminder phase, a short text on the correct execution of the ergonomic posture was sent to the students via WhatsApp twice a day for a month (once before the start of the internship and once during the break), along with their own photo of the same posture. Each day focused on recalling a specific posture, for example, Saturday for the head and neck, Sunday for the shoulders, Monday for the back, and so on. No messages were sent on public holidays. After one month, the intervention group completed the research questionnaires again. The control group completed the questionnaires at the beginning of the study and one month after the start of the study. During this one month, there was no intervention, allowing them to proceed with their internships as usual.

Following the study analysis, educational workshops were offered to the control group upon request, adhering to ethical principles, and providing them with a brochure about the workshop [see Figure 1].

Data collection tool and technique

Two questionnaires were used to collect information in this study. The demographic questionnaire covered field of study, degree, academic semester, age, gender, and marital status, while the ergonomic posture compliance questionnaire, designed by a researcher based on relevant texts and the training program, recorded the degree of compliance with ergonomic posture. The questionnaire contains 48 questions (e.g. “Do you stand with your feet shoulder-width apart when standing?”; “When walking, do you keep your head up and look straight ahead with your eyes?”), rated on a 5-point Likert scale from never to always (never, rarely, sometimes, most of the time, and always).

Initially, a 50-item questionnaire was designed with a Likert scale ranging from always to never. After qualitative and face content validity assessment, two items were removed, resulting in 48 items with quantitative content validity, achieving the overall content validity ratio and content validity index of 0.97 and 0.98, respectively. The questionnaire was then reduced to 48 items with a Likert scale from always to never, indicating reasonable reliability with a Cronbach’s alpha of 0.908.

Statistical analysis method

The data were statistically analyzed using SPSS 21 via descriptive statistics (mean, standard deviation, and frequency) and inferential statistics (t-test, Chi-square test). A value of P < 0.05 was considered significant.

Ethical consideration

Upon approval from the University Research Council and the Ethics Committee, with the Code of IR.MUBABOL.HRI.REC.1401.234, data collection began, ensuring secrecy, confidentiality, and voluntary participation of the research subjects. The research protocol was registered on the IRCT website under the code of IRCT20230701058627N1.

Results

The results indicated that 10 (37%) males and 17 (63%) females were in the intervention group, while 11 (42.3%) males and 15 (57.7%) females were in the control group. Analysis revealed no statistical differences in gender, age, and marital status between the two groups in Table 1. The mean and standard deviation of compliance with MSD prevention behaviors were 154.96 ± 15.85 and 166.77 ± 16.7 in the intervention group before and after the intervention, respectively, and 158.8 ± 15.61 and 159.3 ± 14.6 in the control group before and after the intervention, respectively. The study results showed no statistically significant difference in compliance with MSD prevention behaviors between the intervention and control groups before (P = 0.37) and after (P = 0.09) the intervention in Table 2.

Table 1.

Demographic characteristics of the participants in the experimental and control groups

Characteristics		Control group		Experimental group		Statistic test and P
Age (years) (Mean±SD)		23.19±1.38		23.37±2.33		t=0.33, P=0.73
Gender, n (%)						x2=0.15 df=1 P=0.69
Male		11 (42.3)		10 (37)
Female		15 (57.7)		17 (63)
Marriage status, n (%)						Fisher’s exact test P=0.7
Single		22 (84.6)		24 (88.9)
Married		4 (15.4)		3 (11.1)
Total (n=60)

Table 2.

Comparison of outcome between the control and intervention groups before and after the intervention

Outcome		Control group (Mean±SD)		Intervention group (Mean±SD)		Independent t-test, t		P
Compliance with MSD prevention behaviors (baseline)		158.8±18.76		154.96±15.85		0.88		0.37
Compliance with MSD prevention behaviors (after intervention)		159.3±14.6		166.77±16.7		1.73		0.09

Discussion

The aim of this study was to investigate the effect of training and ergonomic posture on prevention behaviors for MSDs in nursing students. The results showed that there was no statistically significant difference in compliance with MSD prevention behaviors before and after the intervention in the control and intervention groups. Although the score improved in the intervention group, the results were not statistically significant. Yaghobee et al.[24] investigated the ergonomic assessment of dental students’ working conditions and the effect of teaching ergonomic principles on these conditions. They concluded that the training did not lead to a significant change in students’ behavior and that there was no significant difference in the extent of change made in terms of departments, gender, and semester.

It appears that the lack of significance in their study, as in this study, is due to short-term ergonomics training without observation. Meanwhile, the studies conducted in this area suggest different results from the results of this study.

Hamid et al.[25] conducted a study entitled “Effect of an ergonomics training program on nurses’ knowledge and safety practices” and found a statistically significant difference in the assessment of nurses’ ergonomics knowledge except for the conceptual purpose of ergonomics and lifting and moving techniques before and after the implementation of the program, which is not consistent with the results of this study. One of the factors that differentiated their study from ours was that nurses’ knowledge of ergonomics was assessed first, then training was conducted according to previous knowledge, and more training sessions were held than in the ongoing study (seven sessions). Abdollahi et al.[26] conducted a study entitled “Effect of an ergonomic training program on MSDs of nurses working in the operating room.” The results of their study showed that MSDs decreased in the intervention group, which was statistically significant, contradicting the results of the present study. The notable point in their study was to increase the quality of training. To increase effectiveness, the training was conducted in three small groups of 12–13 participants for three consecutive days, and for one group per day. In addition, the subjects were observed for 3 months after the training, which was longer than our study. Moreover, the researcher evaluated the subjects every 2 weeks to determine their educational needs and provide individualized and personalized training with an emphasis on basic training, which is different from this study. Prapti et al.[22] conducted a study titled “Ergonomic program and nursing intervention in nursing students.” The results of their study indicated that the ergonomics program had a significant effect on students’ knowledge, attitude, and behavior of students regarding the ergonomic standard in performing nursing interventions, with a statistical test result of P < 0.05, which is inconsistent with the results of this study. It seems that the reason for this difference was the longer training sessions than in this study (2 months long).

Seifi et al.[27] conducted a study entitled “Ergonomics: A solution to prevent MSDs in intensive care unit nursing staff.” They found that the risk level decreased significantly after the intervention among the nurses in the intervention group compared to the nurses in the control group. The reason for this difference is that the number of training sessions is higher than in this study (four sessions), and also the training time is longer than in our study (6 weeks). Hassan Ali et al.[28] conducted a study entitled “Effect of an ergonomics program on the nurses’ knowledge and practice in the operating room.” They revealed that the nurses’ knowledge and performance improved before and after the intervention, and there was a statistically significant difference. It is worth noting that they divided the nurses into four groups and conducted seven training sessions for each group, which makes their study stand out.

Maroufi et al.[29] carried out a study entitled “Evaluation the effectiveness of ergonomic educational interventions by training the basics of ergonomics and exercise on neck pain in nurse staff of Tohid hospital of Sanandaj.” The results of the interventions demonstrated that there was a significant reduction in neck pain in the intervention group, and there was a statistically significant difference between the control and intervention groups.

In their study, the training sessions took place every 2 weeks for 3 months, and the large number of training sessions may be a reason for the significance of this study.

Ratzon et al.[30] performed a study entitled “Effect of a structured personalized ergonomic intervention program for hospital nurses with reported musculoskeletal pain.” They reported that musculoskeletal pain decreased in the intervention group and that there was a statistically significant difference between the control and intervention groups. One of the factors that differentiates their study from ours seems to be the number of training sessions in the intervention group (initially four sessions for 3 months, then three training sessions for 1 month), and also the training program according to the nurses’ pain level, which makes this study significant. Abbasi et al.[31] investigated the effects of ergonomics training on MSDs in office workers and declared that there was a decrease in the prevalence of MSDs after the implementation of ergonomics training. A study by Shieh et al.[32] examined the relationship between back pain in clinical nurses and high workload. They found that it is necessary to organize occupational health education programs to raise awareness of ergonomics and reduce risks in the workplace so that appropriate postures are adopted to protect the spine.[33,34,35]

Conclusion

As you can see, the results of the studies mentioned above, which were mainly conducted on working nurses, are inconsistent with the results of this study. The reason for this could be the difference in the statistical population of the study, the duration of the training, and the type of follow-up.

The participants in this study were nursing students, while the participants in the aforementioned studies were nurses and operating room staff working in hospitals. According to the studies, the four main factors, including physical environment, organizational conditions, work activities, and patient condition, influence the development of work-related musculoskeletal injuries.[28] This difference may be because the individuals participating in this study were nursing students and were not employed. Therefore, these four factors are different for these individuals than for nurses who were employed and worked independently on the wards, sometimes with intensive shifts and a higher number of patients.

Health policymaking should be based on the principles of innovation, prevention, participation, and continuous evaluation. Adopting these approaches will lead to improving the health status of the community, increasing the efficiency of the system, and responding to the growing and diverse needs of residents. Ultimately, following these solutions can provide effective and sustainable strategies for promoting the general health of individuals and employees and pave the way for long-term health development.

The greater exposure of employed nurses to ergonomic risk factors and the older age of these individuals compared to nursing students may also affect the effectiveness of the intervention and training, ultimately influencing the results of the study. Perhaps all these factors can be considered as reasons for the difference in the results of this study from other studies.

Conflicts of interest

Nil.

Funding Statement

Nil.