Work-related Musculoskeletal Disorders and Quality of Life Among Staff Nurses in a Tertiary Care Hospital of Bangalore

Abstract

Background:

Work-related musculoskeletal disorder (WMSD) is a collective and descriptive term used for the symptoms caused or aggravated by work. Significant WMSDs can affect the productivity and Quality of Life (QOL) of nurses. This study was undertaken to estimate the prevalence of WMSDs, identify their risk factors, and find the association, if any. This study also assessed the quality of life of nurses and its association with WMSDs.

Methods:

This cross-sectional study was conducted among 207 staff nurses at a tertiary care hospital in Bangalore for a period of 7 months (June-2018 to Dec-2018). The nurses were stratified based on their parent department into three broad categories – Medical, Surgical, and Operation Theatre. Stratified random sampling was followed to obtain the required number of nurses from each stratum. Data was collected using a pre-tested semi-structured questionnaire, Nordic Musculoskeletal Questionnaire (NMQ), clinical examination tests, and WHOQOL-BREF.

Results:

The annual prevalence of WMSDs among the study subjects using NMQ was 168 (81.2%). The prevalence of WMSDs based on clinical examination tests was 67 (32.4%). Repetitive movements at work (OR 9.3, 95% CI 3.4-25.7), working in abnormal postures for prolonged periods (OR 4.7, 95% CI 1.7-12.9), and working even when sick (OR 5.3, 95% CI 2.0-14.1) were the risk factors for WMSDs (P < 0.05). No significant association was found between reported WMSDs (according to NMQ) and QOL.

Conclusion:

Our study found that the prevalence of WMSDs was high among the staff nurses and it did not affect their QOL significantly. Workshops and training sessions on ergonomics should be regularly conducted at the workplace to prevent WMSDs.

INTRODUCTION

Work-related health problems result in an economic loss of 4-6% gross domestic product (GDP) for most countries.[1] The term musculoskeletal disorder (MSD) encompasses a gamut of inflammatory and degenerative conditions that affect the muscles, tendons, ligaments, joints, peripheral nerves, and supporting blood vessels with consequent ache, pain, or discomfort.[2] Work-related musculoskeletal disorders (WMSDs) are defined as the musculoskeletal disorders that result from work-related events.[3] According to National Health Profile (NHP) 2018, there are 28,78,632 nurses in India.[4] Nurses routinely perform activities such as lifting heavy loads; transferring patients out of bed, frequent bending to administer intravenous injections, collecting blood samples, having to stand for long durations, and also performing clerical work like billing, record keeping, writing notes, and charts. These tasks at the workplace put nurses at a greater risk for musculoskeletal disorders (MSDs).[5] These disorders can cause sickness absenteeism, decreased productivity, and affect the quality of life (QOL). QOL is defined as an individual's perceptions of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards, and concerns.[6] The relationship between health and illness at work is directly related to QOL. The current study aimed to estimate the prevalence of WMSDs, identify the risk factors for WMSDs, and find their association with QOL.

MATERIALS AND METHODS

This cross-sectional study was conducted at private tertiary care teaching hospital in Bangalore for a period of 1 year (June-2018 to Dec-2018). After obtaining Institutional Ethics Committee (IEC NO 275/2017) clearance and permission from the Chief of Nursing Services (CNS), the list of nurses working in the hospital was obtained from the office of the CNS. It included a total of 926 nurses. From among them, the second list of nurses who had at least 1 year of work experience up to June 2018 in the study hospital was obtained from the Human Resource (HR) Department. It amounted to a total of 749 nurses. The sample size was calculated to be 207. The prevalence of musculoskeletal discomfort was taken as 84% based on a study conducted in Christian Medical College, Vellore, to assess the prevalence of work-related health problems among nurses (n = 500) with an absolute precision of 5% and 95% confidence interval.[7] The nurses were stratified based on their parent department into three broad categories like Medical, Surgical, and Operation Theatre. Stratified random sampling was followed to obtain the required number of nurses from each stratum. Written informed consent was obtained from the nurses before data collection. The interview schedule collected the socio-demographic details of the nurses and their work profile characteristics. Work profile characteristics included details regarding working hours, rest breaks, shift work, overtime work, support and supervision at work, morbidities, sick leaves, etc [attached as Questionnaire]. Self reported Nordic Musculoskeletal Questionnaire general questionnaire (NMQ)[8] was used to determine the prevalence of WMSDs. It consists of 40 choice item questionnaire aided by a body map with 9 symptom sites for respondents to identify any musculoskeletal problem in the previous 12 months and in the last 7 days that prevented them from doing normal activities. Clinical tests namely Cozen's test, Finkelstein's test, Tinel's sign, Phalen's test, and Spurling test were performed to assess the prevalence of Repetitive Strain Injuries (RSIs). The investigator was trained by an orthopedician for conducting the clinical tests. WHOQOL-BREF,[9] a 26 item questionnaire with 4 broad domains and 2 general questions, was used to assess the QOL among nurses. Each item in 4 domains is scored from 1 to 5 with higher scores indicating better QOL. Each domain score ranges from 4 to 20 and the raw score is transformed onto a scale of 0-100. Data collected were entered into Microsoft Excel 2017 and was analyzed using SPSS v21.0

RESULTS

Socio-demographic details and work-related characteristics

The study subjects consisted of 207 staff nurses with a mean age of 27.7 years ± 7.3 years. The majority of the study subjects (100, 48.3%)) were in the age group of 24–27 years and all of them were females (207, 100%). More than half (121, 58.5%) of the study subjects had completed their under-graduation followed by 83 (40.1%) who had completed their diploma. According to the modified BG Prasad classification, 2019,[10] 116 (56.0%) staff nurses belong to the upper middle class and 73 (35.3%) staff nurses belonged to the upper class. The study subjects consisted of staff nurses from Medical departments (131, 63.3%), Surgical departments 58 (28.0%), and operation theatre (OT) 18 (8.7%). The mean years of work experience in the current hospital were 3.9 years ± 4.8 years. More than half of the study population (130, 62.8%) had rest breaks (tea breaks) of duration less than 20 minutes. There were a total of 76 (36.7%) staff nurses who availed sick leave in the previous 1 year. The median number of sick leaves was 5.5. Fever (29, 14.0%) was the most common reason for availing of sick leave. The majority of the study population (131, 63.3%) experienced medium levels of physical stress, and a total of 107 (51.7%) staff nurses experienced medium levels of mental stress in the workplace. The majority of the study population (166, 80.1%) reported no morbidities. Out of those who had reported suffering from morbidity, 12 (29.2%) had migraine or tension headaches followed by 10 (24.4%) with thyroid disorders. There were a total of 10 (24.4%) staff nurses who were obese. None of the nurses reported multiple morbidities.

WMSDs and their determinants

The prevalence of WMSDs among staff nurses in the previous 12 months was 81.2% and in the previous 7 days was 33.8% according to the NMQ. There were a total of 67 (32.4%) staff nurses who were found positive for WMSDs based on clinical examination tests [Table 1]. The most commonly affected regions of the body were the lower back (114, 55.1%) followed by the neck (90, 43.5%), and shoulders (89, 43.0%). Among 35 (16.9%) of the staff nurses, symptoms in the lower back region were disabling enough to prevent them from doing their normal work. The majority of the staff nurses (79, 38.2%) were affected by WMSDs in 1-3 anatomical sites. There were a total of 39 (18.8%) staff nurses with more than 6 body regions affected by WMSDs. The distribution of WMSD according to clinical tests is given in Table 2.

Table 1.

Prevalence of WMSDs (n=207)

WMSDs	During last 12 months n (%)	During last 7 days n (%)	Positive for atleast one Clinical examination tests n (%)
Present	168 (81.2)	70 (33.8)	67 (32.4%)
Absent	39 (18.8)	137 (66.2)	140 (67.6%)

Table 2.

Distribution of study population according to the clinical examination tests for WMSDs (n=207)

Clinical tests	Positive (n, %)	Negative (n, %)
Cozen’s test for lateral epicondylitis,	34 (16.4)	173 (83.6)
Finkelstein’s test De Quervain’s tenosynovitis.	24 (11.6)	183 (88.4)
Tinel’s sign of median nerve injury	21 (10.1)	186 (89.9)
Phalen’s test for Carpal Tunnel Syndrome	5 (2.4)	202 (97.6)
Spurling’s test for cervical radiculopathy	13 (6.3)	194 (93.7)

The numbers represented above are not mutually exclusive

Out of those staff nurses who experienced work-related pain, the majority of them 75 (51.1%) had taken self-treatment. There were 49 (33.3%) staff nurses who did nothing for the work-related pain while 23 (15.6%) staff nurses sought professional help for work-related pain.

There was no statistically significant association between job satisfaction and WMSDs. Staff nurses involved in doing repetitive movements, frequent bending at work, lifting or moving heavy weights at work, working in abnormal postures for prolonged periods, and who were working in congested workstations were an increased chance of developing WMSDs [Table 3]. These were reported subjectively by the study participants.

Table 3.

Association between other work-related characteristics and WMSDs (n=207)

Work related characteristics	WMSDs		Test statistic	P
	Yes	No
Type of employment
Temporary	49 (73.1)	18 (26.9)	4.172	0.041a*
Permanent	119 (85.0)	21 (15.0)
Department
Medical	104 (79.3)	27 (29.7)	1.442	0.508
Surgical	50 (86.2)	8 (13.8)
Operation Theatre (OT)	14 (77.7)	4 (22.3)
Repetitive movements
Yes	129 (90.8)	13 (9.2)	27.744	<0.01a*
No	39 (60.0)	26 (40.0)
Frequent bending
Yes	128 (88.2)	17 (11.8)	16.034	<0.01a*
No	40 (64.5)	22 (35.5)
Lifting heavy weights
Yes	99 (87.6)	14 (12.4)	6.773	0.012a*
No	69 (73.4)	25 (26.6)
Working in abnormal postures
Yes	118 (89.4)	14 (10.6)	16.156	<0.01a*
No	50 (66.7)	25 (33.3)
Work when sick
Yes	134 (90.5)	14 (9.5)	29.885	0.005a*
No	14 (9.5)	25 (42.3)
Job satisfaction
Yes	96 (80)	24 (20)	0.251	0.720a
No	72 (82.8)	15 (17.2)
Received occupational training
Yes	74 (76.3)	23 (23.7)	2.832	0.110a
No	94 (85.4)	16 (14.6)
Congestion of workstation
Yes	107 (86.3)	17 (13.7)	5.324	0.029*
No	61 (73.5)	22 (26.5)

(Figures in parenthesis indicate row percentages). a=Chi-Square Test; b=Fisher’s Exact Test. *=P<0.05

Multivariate linear regression was performed by including all other factors which were found to be statistically significant in the bivariate analysis as the independent variable and taking work-related musculoskeletal disorders as the dependent variable. Repetitive movements at work (OR 9.3, 95% CI 3.4-25.7), working in abnormal postures for prolonged periods (OR 4.7, 95% CI 1.7-12.9), and working even when sick (OR 5.3, 95% CI 2.0-14.1) were the risk factors for WMSDs (P < 0.05) [Table 4]. The staff nurses had a mean score of 72.0 (± 19.9) in the Social domain and 65.9 (±13.8) in the psychological domain. The staff nurses had a mean score of 64.4 (± 14.1) in the Physical domain and 61.0 (±14.9) in the Environmental domain. The majority of the study population (140, 67.6%) reported good QOL, and (128, 61.8%) good health status.

Table 4.

Association between work-related factors with WMSDs: multivariate linear regression. (n=207)

Factors	WMSDs OR	CI Lower bound	CI Upper bound	P
Repetitive movements	9.329	3.391	25.666	0.000*
Frequent bending	2.376	0.874	6.482	0.090
Heavy weights	1.202	0.441	3.273	0.719
Workplace congested/overcrowded	1.820	0.680	4.873	0.233
Working in abnormal postures for prolonged periods	4.666	1.681	12.951	0.003*
Work even when sick	5.274	1.967	14.138	0.001*
Work related pain	2.338	0.830	6.590	0.108

OR=Odds Ratio; CI=Confidence Interval. * = P<0.05

Staff nurses belonging to lower socioeconomic classes scored low in social and environmental domains compared to nurses in the upper socio-economic class. Staff nurses with low physical stress had a better QOL in the physical and environmental domain. There was no statistically significant association between WMSDs (in the previous 12 months) and QOL. There was a statistically significant association between WMSDs based on clinical examination tests and QOL in the physical domain [Table 5].

Table 5.

Quality of life and its determinants (n=207)

Socio-Economic status	Quality of life - Median (IQR)
	Physical	Psychological	Social	Environmental
Class I	64.2 (53.5-75.0)	62.5 (58.3-75.0)	75.0 (58.3-75.0)	62.5 (50.0-68.7)
Class II	67.8 (57.1-75.0)	66.6 (59.3-79.1)	75.0 (62.5-87.5)	65.6 (53.1-71.8)
Class III and above	67.8 (42.8-69.6)	58.3 (39.5-70.8)	62.5 (50.0-75.0)	56.2 (34.3-59.3)
P	0.114a	0.570a	0.01a*	0.01a*
Physical stress
High	64.2 (53.5-71.4)	62.5 (54.1-79.1)	75.0 (62.5-87.5)	59.3 (46.8-68.7)
Medium	67.8 (53.5-75.0)	66.6 (58.3-75.0)	75.0 (62.5-83.3)	62.5 (53.1-71.8)
Low	71.4 (57.1-76.7)	70.8 (52.0-81.2)	62.5 (43.7-83.3)	65.6 (54.6-84.3)
P	0.023a*	0.272a	0.542a	0.030a*
WMSD (in the previous 12 months)
Yes	64.2 (53.5-75.0)	66.6 (55.2-75.0)	75.0 (58.3-87.5)	62.5 (50.0-71.8)
No	67.8 (64.2-75.0)	70.8 (58.3-79.1)	75.0 (75.0-87.5)	62.5 (59.3-68.7)
P	0.134b	0.054b	0.566b	0.349b
WMSDs based on clinical examination tests
Yes	64.2 (50.0-71.4)	62.5 (54.1-75.0)	75.0 (50.0-87.5)	62.5 (46.8-71.8)
No	67.8 (57.1-75.0)	66.6 (58.3-75.0)	75.0 (62.5-87.5)	62.5 (53.1-71.8)
P	0.047b*	0.286b	0.569b	0.779b

a=Kruskal-Wallis test * = P<0.05. b=Mann Whitney U test * = P<0.05

DISCUSSION

Prevalence of WMSDS

WMSDs are one of the commonest occupational health problems which are preventable. Few studies have been done among nurses to assess the prevalence of WMSDs and very few studies are available that look at the QOL among nurses in India. The annual prevalence of WMSDs among staff nurses was high in this study [Table 1]. However, this is slightly lesser compared to other studies done in India. A previous study from Maharashtra,[5] reported that the prevalence of WMSDs among nurses in the previous 12 months was 89.1%. 16 In a study done among nurses in Gujarat[11] an annual prevalence of 89.2% was reported for WMSDs. By individual body site, the lower back was the most common region affected followed by neck, shoulder, and upper back. In a study done in rural Japan among nurses,[12] the annual prevalence of WMSDS was reported to be very high (91.2%) and the shoulder region was the most commonly affected site followed by the lower back and neck. The difference in prevalence rates and order of sites affected could be explained by several possible factors – different workplace settings such as rural and urban, socio-cultural factors and improperly designed equipment, tools or workstations, and duration of employment. Based on number of anatomical sites affected, more than one-third of the staff nurses were affected by WMSDs in 1-3 anatomical sites. Thus, it is evident that multi-site pain or discomfort of the musculoskeletal system is a common health problem observed among nursing personnel.

Association of different factors with prevalence of WMSDs

No statistically significant associations were found between socio-demographic factors and WMSDs. There was no significant association between type of department and WMSDs. This finding is consistent with findings from a study done in Gujarat.[11] More than two-thirds of the staff nurses reported that they receive good support from superiors at work. A previous study from Africa,[13] reported that good supervision and management were found as motivational factors for nurses to work. Less than one-fifth of nurses sought professional help for work-related pain. Similarly, in a study done,[14] among Malaysian nurses, 20% of the nurses sought professional help. This might reflect the poor level of awareness about WMSDs among the nurses. On bivariate analysis, repetitive movements, frequent bending, lifting heavy weights, congested workstations, working in abnormal/awkward postures, and working even when sick was found as work-related risk factors significant for the development of WMSDs [Table 3]. On further multivariate analysis taking the prevalence of WMSDs, repetitive movements at work working in abnormal postures for prolonged periods, and working even when sick remained as risk factors for the development of WMSDs [Table 4].

Quality of life of the study population and associated factors

The self-reported QOL was good according to a majority of the nurses in this study and the majority of the study population reported good health status despite the high prevalence of WMSDs detected. The following can be possible explanations for the above findings – most the nurses assume that pain and discomfort are part of their work due to physical tasks involved in it and since the majority of them had the same problem they might as well ignore it since it is a common problem for all. The staff nurses in this study had a higher mean domain score (70.62) in the social domain. This finding is consistent with the findings of a similar study[15] in which nurses from two hospitals had higher mean scores (72.24; 69.54) in the social domain. This indicates that they maintain good interpersonal relationships with their peers and family. No significant association was found between reported WMSDs according to NMQ and QOL [Table 5]. This is, in contrast, to a study conducted in Brazil,[16] where it was found that QOL was reduced among individuals with MSD. The probable reason for this difference in findings might be due to variations in study population and study tools used. However, there was a significant association between WMSDs based on clinical examination tests and QOL in the physical domain. Staff nurses with WMSDs based on clinical examination tests had poor QOL in the physical domain compared to those without WMSDs based on clinical examination tests – clinically positive tests may indicate a more severe disorder.

Recommendations

The high annual prevalence of WMSDs among staff nurses implies the need to create awareness among them regarding prevention strategies such as proper lifting and transfer techniques, sitting postures, and reduction of workload. Adequate rest breaks for 5 minutes every hour should be provided for relaxation exercises during work. These are easy to implement, inexpensive, and can make up for workplace deficiencies. Job rotation can be followed between various departments to ensure that the same muscle groups are not engaged for extended periods of time. Staff nurses should be encouraged to adopt healthy lifestyles. Appropriate infrastructural facilities should be provided to improve their physical fitness and dietary habits. Annual medical examinations and pre-placement examinations can help in providing medical help and support to nurses.

Limitations

The study was conducted at one private tertiary care hospital in Bangalore, Karnataka. This affects the generalisability of the results to nurses outside the study hospital. As the staff nurses were interviewed on the hospital premises, it is possible that some of them could have either under-reported or over-reported stress associated with work and the working conditions of the hospital depending on their individual perceptions.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Questionnaire

Social and Demographic characteristics:

1. Name:

2. Age:

3. Sex:

4. Current Address:

5. Permanent Address:

6. Phone number:

7. Education: a. ANM b. GNM c. BSc nursing d. MSc nursing

8. Marital Status: a. Singleb. Married c. Divorced d. Separated e. Widow

9. Married Life duration :__________ years

10. Number of children: _____________

11. Salary/month: _____________

12. Total number of family members:___________

13. Family income/month: _____________

14. Per-capita income: _____________

15. Type of housing: a. Self-owned houseb. Rented house c. Paying Guest hostel d. St.John's provided hostel e. Company/Hospital provided residence

16. Are you regularly involved in physical activities such as exercise/sports/yoga?If yes please specify:

    Type of activity: _____________Number of minutes/day: _____________

17. Habits:Tobacco: a. Yes b. NoAlcohol: a. Yes b. No

Work – related characteristics:

1. Current Designation:

2. Department/Ward in which you are working: a. Medical b. Surgical C. operation theatre

3. Work experience(years): Present (in St. John's Hospital)_____________years: Past_____________years

4. Type of post: a. Temporary position b. Permanent position

5. Distance of residence from work : ______________Time travelled :_____________ minutes

6. Mode of travel to workplace:_____________

7. Number of working hours per day: a. <8 hrsb. >8 hrs

8. Do you have shift work? a. Yes b. No

9. Number of night shift days per month: _____________

10. Do you work overtime? a. Yes b. No If yes how many hours/day?_____________hours

11. Average resting time during work: a. < 20 min b. >20 min

12. Does your work involve:

    n: _____________

1. Salary/month: _____________

2. Total number of family members:___________

3. Family income/month: _____________

4. Per-capita income: _____________

5. Type of housing: a. Self-owned houseb. Rented house c. Paying Guest hostel d. St.John's provided hostel e. Company/Hospital provided residence

6. Are you regularly involved in physical activities such as exercise/sports/yoga?If yes please specify:

   Type of activity: _____________Number of minutes/day: _____________

7. Habits:Tobacco: a. Yes b. NoAlcohol: a. Yes b. No

Work – related characteristics:

1. Current Designation:

2. Department/Ward in which you are working: a. Medical b. Surgical C. operation theatre

3. Work experience(years): Present (in St. John's Hospital)_____________years: Past_____________years

4. Type of post: a. Temporary position b. Permanent position

5. Distance of residence from work : ______________Time travelled :_____________ minutes

6. Mode of travel to workplace:_____________

7. Number of working hours per day: a. <8 hrsb.>8 hrs

8. Do you have shift work? a. Yes b. No

9. Number of night shift days per month: _____________

10. Do you work overtime? a. Yes b. No If yes how many hours/day?_____________hours

11. Average resting time during work: a. < 20 min b. >20 min

12. Does your work involve:

    • a)Repetitive movements? a. Yes b. No
    • b)Frequent bending at – wrist, elbow, shoulder, neck joints? a. Yes b. No
    • c)Lifting/ moving heavy weights or involved in shifting patients at work? a. Yes b. No
    • d)Do you feel that your work station is overcrowded/ congested? a. Yes b. No

13. Do you work in abnormal postures for prolonged periods? a. Yes b. No

14. Do you supervise people in your work? a. Yes b. No

15. Do you receive good support from your colleagues at work? a. Yes b. No

16. Do you receive good support from your superiors at work? a. Yes b. No

17. Do you feel satisfied with your job? a. Yesb. No

18. Number of days of leave you have availed in the last 1 year: _____________

19. Number of days of sick leave (leave due to illness) you have availed in the last 1 year: _____________ Reasons(specify) _____________

20. Have you experienced work related pain in the last 6 months? a. Yes b. No

21. Did you do anything to relieve pain? a. Did nothing b. Self treatment c. Professional Help

22. Do you work even when you are sick? a. Yes b. No

23. How physically Strenuous is your work? (as perceived by the subject): a. High b. Medium c. Low

24. How mentally Strenuous is your work? (as perceived by the subject): a. High b. Medium c. low

25. Have you received any training in occupational health at the work-place? a. Yes b. No

26. History of fall/ accidents/injuries in the past 1 year: _____________

27. History of any hospital admissions in the past: _____________

28. Co-morbid illness: Diabetes Mellitus/Hypertension/Cardio-vascular diseases/others _____________

29. Do you have Job rotation? a. Yes b. No

Tests for Repetitive strain injuries:

Type of test	Right	Positive	Left	Positive
Cozen's test
Finkelstein's test
Phalen's test
Tinel's t est of the median nerve
Spurling test