Work-related musculoskeletal disorders in nurses working in the Kingdom of Saudi Arabia

1 Introduction

Musculoskeletal disorders encompass disorders and injuries of the muscles, nerves, tendons, joints, cartilage, and spinal discs. Work Related Muscular Disorders (WRMDs), or Work Related Musculoskeletal Disorders (WMSDs) are conditions in which, “the work environment and performance of work contribute significantly to the condition and/or the condition is made worse or persists longer due to work conditions” (p.1) [1]. Musculoskeletal disorders do not include conditions caused by falling or similar work-related accidents, rather they refer to disorders caused by repetitive action, overexertion, or bodily reaction. Common examples of WRMDs include sprains, back pain, carpal tunnel syndrome, and hernia [1].

Studies have shown that healthcare workers are predisposed to WRMDs [1]. Nurses are considered the group of healthcare workers with the highest prevalence of WRMDs [2, 3]. A study published in the American Journal of Industrial Medicine found that WRMDs are highly prevalent in nurses, with nearly 50% of nurses reporting neck and back problems annually [4]. A study analyzing healthcare workers in India found that nurses are at the highest risk for developing WRMDs [5]. Among the health professionals evaluated in this study the most common area of injury was the lower back, followed by neck pain, shoulder pain, and finally knee and ankle pain. Contributing factors were found to be working in one position over long periods of time, working in awkward or tight positions, and working hands-on with multiple patients during one shift. The specific tasks identified as most likely to lead to WRMDs are assisting patients in gait training/ambulation, repetitive tasks, and tasks requiring bending or twisting while in a cramped position [5].

There are many studies reporting on the significant numbers of nurses affected by WRMDs internationally. These studies report a range for the number of nurses affected by WRMDs from around 40–85%. A systematic review of studies published in English in professional journals between 1990–2012 found that the rates of WRMDs in nurses range from 40–75% [6]. Specific studies done internationally report the following statistics: A study done in Vietnam found that approximately half (47.8%) of the RNs in the country are affected by WRMDs annually [7]. A study in Thailand which analyzed a nationally representative sample using the Thai Nurse Cohort concluded that 74.7% of the RNs experienced WRMDs in the past 12 months [8]. In a study done in Lisbon, Portugal, 84% of nurses reported a WRMD in the past 12 months [9]. In a study done on Turkish hospital nurses, 79.5% were found to have a WRMD in the past 12 months [10]. A study done in the Netherlands found that 36% of nurses experience back pain, and significant numbers experienced neck, arm, and leg injuries in addition [11].

The role of nurses varies depending on the setting they work in, their patient population, and their specific training. Nurses typically are responsible for medication management and administration, patient positioning, patient transfers, hygiene care, wound care, patient feeding, and charting and documentation; all of which contribute to significant time spent standing, bending, and twisting [12]. Nurses often are required to perform tasks repeatedly throughout the day [2]. The most common physical demands of nursing that have been found to contribute to WRMDs include lifting, working in awkward postures, stooping, and repetitive actions [4, 10]. These physical demands are frequent when transferring and/or repositioning patients who are prone in bed [13]. Lower back pain has been identified as the most frequent WRMD related to the job function of nurses [2–4].

Research from the Canadian Centre for Occupational Health and Safety [CCOHS], 2014 and Occupational Safety and Health Administration [OSHA], 2014 shows that a variety of factors contribute to the development of WRMDs. Repetitive movements, forces, and postures, and continuous exposure to vibration and temperature increase likelihood of WRMDs. When an individual repeatedly does the same movement without rest breaks, the muscles that contract are not sufficiently recovering, and causing fatigue. The angles of the shoulders, elbows, and wrists change the amount of force needed to complete a task so it is important to consider the actual stress or weight that is put on the body part. Vibration is a concern because it may cause tactile deficits in the skin such as numbness and tingling. Cold temperatures will also create numbness. Workstations may create a physically inefficient space for employees with WRMDs due to a combination of these factors, which increases the likelihood of WRMDs. Additional stress may be added to the body’s joints or muscles if the work tasks require the individual to perform at faster speeds or carry heavy products. Maintaining any position, whether standing or bending down, for long periods of time will exacerbate the injury as well [13, 14].

The consequences of WRMDs include injury and pain to joints, muscles, tissues, tendons, and nerves, which can affect any region of the body [13, 14]. Repetitive stress and pressure on the same part of the body will cause it to deteriorate, become painful, and functionally impaired [15]. A study by Pinar (2010) collected data on WRMDs prevalence in Turkish nurses. The most affected regions in descending order were the low back (49.7%), shoulders (38.0%), neck (35.0%), legs (30.0%), and upper back (19.2%). Additionally, 13.7% of the nurses reported that a combination of body parts were affected by WRMDs [10]. The joints in the upper extremities are also frequently affected in the elbow, wrist, and hand [1]. Commonly seen diagnoses in the upper extremities include arthritis, tendonitis, sprains, and carpal tunnel syndrome [16].

As a result of WRMDs, nurses are absent from work to facilitate their recovery process. This absence may create adverse effects on the individual including decreased income due to the decline in productivity for the employer [16]. Individuals with WRMD also should consider the negative effect of this impairment on their mental state. According to Carriere, Thibault, and Sullivan (2015), up to half the individuals with WRMD demonstrate depressive symptoms and have double the work absence as their colleagues who are unaffected by WRMDs [17]. The increased absence from work, decreased productivity, increased costs of medical care and surgical interventions, and possible disability of the individual with WRMDs weigh heavily on the employer [1].

The role of occupational therapy in addressing WRMDs include prevention of injury through education of employees and management, adaptation and modification of work tasks, and ergonomic evaluations. An OT would consider the vocational aspect of the nurse with WRMDs and evaluate the factors that contribute to the injury within the work environment [18]. Research by Boynton and Darragh (2008) provide evidence for the effectiveness of OT interventions to prevent WRMDs. An ergonomic evaluation by the OT would consist of observing movements in the natural context, analyzing the physical stress that it causes, and reducing bad postures or repetitive muscle use. Modifications to the task are recommended to improve body mechanics. The OT provides education for the staff and administrative team to promote awareness and reporting early detection of discomfort or pain that may cause WRMDs. Implementation of rest breaks or decreasing work hours are suggested with management approval. The OT would also contribute to adapting the engineering controls of any transportation requirements of work tasks. Examples include evenly distributing the weight inside a box or adding handles for easier carrying [19]. OT is shown to have beneficial effects, which “include reduced pain and suffering, both from prevented disorders as well as reduced severity in those disorders that do occur, decreased numbers of workers’ compensation claims, and reduced lost work time” [15].

In the Kingdom of Saudi Arabia (KSA) there is scant studies about this topic. Therefore, the purpose of this study was to explore that magnitude of the WRMDs among nurses in KSA, to explore what possible injuries can affect nurses, and what body parts affected by wrong biomechanics of lifting among nurses. Exploring the role of OT in increasing awareness and prevention of WRMDs among nurses was another purpose of this study.

2 Methods

3 Results

Participants were all nurses according to the purpose of this study (n = 94). About 150 questionnaires were distributed, the reponse rate was about 63%. Majority of participants were female (97.9%). Most of the nurses participated in this study were 26–35 years old (62.7%). Regarding the years of experience in doing nursing, 41.5% had 1–5 years experience and less than 10% had an experience of more than 15 years. All of the participants were full time employees working more than 35 hours a week. They were all bedside nurses working in the medical and surgical wards, Intensive Care Unit (ICU), and the orthopedic ward and work directly with patients. According to their Body Mass Index (BMI), only seven participants (7%) were obese (BMI > 30), 27 (29%) were overweight (BMI 25–29.9), seven (7%) were underweight (BMI less than 18.5), while most of the participants, 53 (57%) were normal/healthy weight (BMI 18.5–24.9) (Table 1).

According to participants’ answers on The NMQ most of them (63.8%) indicated that they experienced discomfort during the last 12 months in their lower back, followed by shoulders (50%), and upper back (48.9%). Those who indicated that they experienced lower back discomfort were the higher group that have been prevented from carrying out normal activities during the last 12 months (13.8%), followed by those who had discomfort with their upper back (11.7%), and shoulders and wrist/hands discomfort (9.6% each). Most of those who indicated that they have seen a physician during the last 12 months for their conditions were from those who experienced pains with their lower back (12.8%), followed by wrist/hands (9.6%), and shoulders and ankles/feet (6.4 % each). Of the participants (19.1%) reported that they experienced discomfort of their shoulders, followed by lower back (17%), and upper back (13.8%) during the last seven days (Table 2).

On replying to the last part of the NMQ that focuses on the participants’ discomfort in their low back, neck, and shoulder. Majority of the participants (68.1%) indicated that they experienced discomfort with their lower back, that led two of them (2.1%) to change their jobs/duties, with 38 (40.4%) had one to seven days of discomfort, and 22 (23.4%) were prevented from doing their normal work one to seven days as well. Twenty-four (25.5%) of the participants who indicated experiencing low back discomfort, also indicated that this discomfort reduced their work activity, and same number indicated that the discomfort reduced their leisure activity. Six of the participants with low back discomfort (6.4%) reported that they were hospitalized due to this discomfort, and 14 (14.9%) reported that they have seen a doctor or other health professionals because of this trouble (Table 3).

On the other hand, 38 participants (40.4%) experienced shoulder discomfort that led only one of them to change his/her job/duties, with 19 (20.2%) that had one to seven days of discomfort, and 11 (11.7%) were prevented from doing their normal work one to seven days as well. Eight (8.5%) of the participants who indicated experiencing shoulder discomfort, also indicated that this discomfort reduced their work activity, and 7 (7.4%) participants indicated that the discomfort reduced their leisure activity. Only 6 (6.4%) participants reported that they have seen a doctor or other health professionals because of their shoulder discomfort, and none of the participants reported being hospitalized due to shoulder discomfort (Table 3).

About one third of the participants (31.9%) reported that they experienced neck discomfort. None of these participants had to change his/her job/duties. Those who reported that they experienced one to seven days of discomfort during the last 12 months were 14 (14.9%), and 10 (10.6%) were prevented from doing their normal work one to seven days for the last 12 months. Nine (9.6%) of the participants who indicated experiencing neck discomfort, also indicated that this discomfort reduced their work activities, and same number indicated that this neck discomfort also reduced their leisure activities. Only 5 (5.3%) participants reported that they have seen a doctor or other health professionals because of their neck discomfort, and none of the participants reported being hospitalized due to neck discomfort (Table 3).

The purpose of this study was to explore that magnitude of the WRMDs among nurses in KSA. It is assumed that awareness about WRMDs might have an impact on the prevalence of this problem. The findings of this study was not significantly different from findings of other related studies.

Lower back problem was the most prominent cause of discomfort as reported by almost 64% 0f the participants. Some of those experienced this problem were prevented from carrying out normal activities and needed to be seen by the physician for this condition. These findings were consistent with findings of other studies [3, 6–11]. Lower back problem was followed by shoulders, upper back, ankles/feet, and neck problems respectively. Although reviewed studies reported same problems, but the exact order of the problems were not consistent. What is important here is the significant magnitude of WRMDs among the nursing staff.

The consequences of WRMDs are experienced by the targeted population were mainly related to feelings of discomfort that lasted for more than one day and even more than a month for some of them. This also impacted their work and leisure activities. More than 6% of the participants needed to be hospitalized mainly due to low back pain. This in return led nurses to get sick leaves from their work, decrease their productivity, influence their mental state, and increase the costs of medical care. These findings were also consistent with findings from other studies [1, 17].

Accordingly, WRMDs seem to be a global problem among bedside nurses. This is not surprising providing the nature of nurses’ job that requires long standing hours, bending, and twisting to perform necessary daily duties of patient positioning, patient transfers, hygiene care, wound care and many other physically stressful activities as reported by Vulcan (2017) [12]. Actions must be taken into consideration to control this problem and its consequences on the physical and psychological health and wellbeing of the nursing staff as they are the main working forces in any hospital.

This WRMDs among nurses should be addressed and managed in each hospital to prevent its consequences. Most hospitals have rehabilitation facilities that include occupational therapy services. Accordingly, such services should be utilized since WRMDs best addressed in the scope of occupational therapy practice. OTs should focus on increasing nurses’ awareness about the magnitude of WRMDs and proper body mechanics. Evaluating the working environment of the nurses and related ergonomic hazards should be identified by the occupational therapists. Proper environmental modifications should be implemented in the work area. Nurses, in groups or individually, should be instructed on main causes of WRMDs such as repetitive movements, improper patient’s handling during mobility and transfer such as bending and twisting, standing for long hours, and performing work activities in awkward postures. Nurses usually work 12 hours shifts for three or more consecutive days, this present cumulative physical stress over their bodies as time passes. They should be allowed for more frequent breaks during the day. Nurses lounges should be quiet and provided with relaxing chairs. Nurse to patient ratio should not exceed the accredited standards. Mechanical devices such as transfer lifts should be available to nurses and should be used. Lifting teams and team work should be enforced and utilized with all bedridden, and mobility and functionally dependent patients. Bedside nursing job is a highly physically and psychologically demanding job. Nurses need to be physically fit to handle this job. OT training programs targeting nurses should focus on range of motion, stretching, and strengthening exercises to all body parts with special focus on the back, shoulders, neck, and lower and upper extremities. Such a program should be trained and supervised by the OTs at the beginning, where nurses doing the exercises need to be observed for proper conduction. Afterwards, nurses can do these exercises on their own at least three times per week to improve their physical fitness. The exercises can be done either in their living places or at work. Periodical follow ups and observation, every two or three months, by the occupational therapists should be done to make sure that the nurses are implementing the exercises properly.

Even though this study was conducted in a large medical city (KAMC), its results cannot be generalized. It is recommended that future studies should target nurses in different hospitals in Riyadh, with larger sample sizes. Future studies should utilize more outcome measures that target not only the physical aspect but also the psychosocial aspects of the nurses. An implementation of the proposed recommendations with a follow up evaluation using various outcome measures should be conducted to prove the effectiveness of such programs and its value on the nurses’ overall job satisfaction and wellbeing.

5 Conclusion

Nurses are at high risk for WRMDs. Occupational therapists have an important role to play in this area. Measures should be taken by hospital administrators, the rehabilitation departments, as well as the nurses themselves to manage this global problem. Nurses represent the largest health professionals in each hospital and their role is vital in patients’ care. Therefore, special measures should be implemented to make sure that they work in ergonomically appropriate environment and implement proper body mechanics to limit their chances of encountering WRMDs.

Conflict of interest

None to report.