Do sleep and psychological factors influence musculoskeletal pain among nurses?

Abstract

BACKGROUND:

The physical factors associated with musculoskeletal pain in nursing personnel have been largely investigated, although the role of sleep and psychological factors resulting in musculoskeletal pain has not been addressed thoroughly.

OBJECTIVE:

This study aimed to explore the prevalence of musculoskeletal pain and investigate how sleep and psychological factors influence musculoskeletal pain in a nursing group.

METHODS:

Nordic standard questionnaires were distributed to 230 female nurses. Chi-square tests were performed to assess the associations between sleep problems, psychological problems, and musculoskeletal pain symptoms. Binary logistic regression analysis was also conducted to identify the primary factors influencing the prevalence of musculoskeletal pain.

RESULTS:

The highest prevalence of pain was observed in the lower back, neck, and shoulders, whereas the lowest prevalence of pain was observed in the ankles, feet, elbows, and hips/buttocks. Chi-square analysis and binary logistic regression showed that sleep duration, sleep onset time, and sleep quality all significantly contributed to the development of neck and upper back pain. With regard to the psychological factors, only occupational pride and stress had a significant effect on pain; in contrast, family support did not show any significant influence.

CONCLUSION:

Compared with other body regions, musculoskeletal pain in the lower back, neck, and shoulders requires more attention and preventive interventions. Special efforts should be made to shift the workday system of the nursing group because of the strong correlation between sleep problems and pain. Incentives other than penalty mechanisms should be considered seriously in nursing to boost occupational pride and relieve job stress.

Keywords

Nursing musculoskeletal pain Nordic standard questionnaires binary logistic regression analysis

1 Introduction

Few epidemiological studies evaluating the prevalence of musculoskeletal pain among nursing personnel in China have been conducted or published. At the end of 2020, there were about 9 million beds in medical and health institutions nationwide, but only about 4 million registered nurses [1]. China only has 3.34 nurses per thousand people [1], while the United States has 11.8, Japan has 11.8, South Korea has 7.9 and Switzerland has 18.0 nurses per thousand people [2]. Statistics from the China Human and Social Security Department showed that most nurses have to perform night shift work and repetitive activities, such as stooping the wrist and inclining their neck, more frequently than the personnel belonging to other occupational groups [3]. Moreover, nurses need to maintain the balance between work and family life, thus increasing their risk for impaired sleep quality. With the development of the concept of high-quality nursing and increasing public demand for healthcare services, pressure on the nursing profession is increasing, which imposes a psychological workload on the nursing group.

Work-related musculoskeletal disorders (WRMSDs) are becoming increasingly prevalent among nurses [4]. The prevalence of musculoskeletal pain in the medical industry is relatively high and is 40%–92% in nurses [5 –7]. The incidence rates of skeletal muscle pain in the lower back, neck, shoulder, and hip/leg were 72% [7], 61.21%, 57.82%, and 51.03%, respectively [8]. Musculoskeletal pain imposes large costs on the employees and society [9] and may have numerous consequences, such as reduced quality of life, occupational disability, absence of sickness, and changing or discontinuing a profession [10, 11].

The reasons for musculoskeletal pain have aroused the interest of researchers over the past decades. Musculoskeletal disease is a complex pathological condition caused by a number of factors. Environmental, psychological, individual, and other factors contribute to the occurrence of musculoskeletal diseases [12]. Epidemiological studies have shown that awkward postures, heavy manual handling and transfer of patients, repetitive movements, monotonous tasks, and standing for prolonged hours are ergonomic risk factors associated with nursing jobs [13 –15]. Age, sex, workload, and work department are also important risk factors for musculoskeletal diseases [16, 24]. However, previous studies have mainly focused on examining the physiological factors related to musculoskeletal pain in nursing personnel, with little consideration on the effects of psychological factors and sleep deprivation.

The remainder of this paper is organized as follows: Section 2 introduces the study’s methodology. Section 3 presents the results of the study. Finally, the discussion and conclusions are presented in Sections 4 and 5, respectively.

2 Methods

2.1 Participants

From April 2021 to June 2021, a panel of registered female nurses working in a first-class hospital in Beijing were recruited, and their musculoskeletal pain and related factors were investigated. All participants from the intensive care units, wards, emergency rooms, operating rooms, and other departments had >12 months of work experience. The total sample size was 189, and the participants’ average age was 29.8 years. The average working age was 7.7 years, the average height was 162.4 cm, and the average weight was 56.9 kg. The study was approved by the Ethical Review Committee of the university, and written informed consent was obtained from all participants.

Inclusion criteria: (1) Worked in the hospital for ≥1 year; (2) Have a nurse practitioner qualification certificate; (3) No rotation to other departments within 12 months; (4) Voluntarily participation in the research and sign the informed consent form.

Exclusion criteria: (1) Nurses who are currently not on the job, such as those who go out for further study, maternity leave and sick leave; (2) Nurses who are pregnant and lactating within 1 year; (3) Nurses with musculoskeletal injuries caused by non-work factors such as congenital spinal disorders, tumors, and gynecological diseases; (4) Those with a clear history of trauma and surgery in the past 1 year; (5) Practical nurses.

2.2 Interview

Before the distribution of questionnaires, all experienced nurses were interviewed to identify the most probable risk factors for musculoskeletal pain. The first edition of the questionnaire was distributed to these nurses, and any suggestions for revising the questionnaire were obtained. The interviewed nurses from various wards were investigated to improve the reliability of the study and were found to have at least 3 years of nursing experience. The interview verified the questionnaire’s aptness for determining the employment characteristics and clarity of the included questions.

2.3 Questionnaire

The questionnaire used in this study was developed based on the Nordic standard questionnaire [17], translated into Chinese language by the corresponding author, and evaluated by a professional panel. It includes questions that assess the symptoms and duration of musculoskeletal pain over the last 12 months. The collected data were derived from three main aspects. The first part involved the collection of anthropological information (age, body mass index (BMI), marital status, current occupational ward, and nursing experience). The second part involved the collection of the following potential psychological and sleep factors: sleep quality, sleep duration, family support, work satisfaction, and stress. The last part involved the collection of pain reports from the nine body regions. Sleep quality can be classified into the following three levels: high, intermediate, and low. The sleep duration was grouped into three categories: <6 hours, short sleep; 6–8 hours, reference group; and >8 hours, exceeding level. The sleep onset time was divided into three categories: before 11 pm, 11 pm to 12 am, and after 12 am. The psychological factors included occupational pride and work stress, both of which had three levels: high, intermediate, and low. The outcome of musculoskeletal pain was measured using the Nordic standard questionnaire with an explainable picture in addition to the questions; the reliability and validity of this questionnaire have previously been validated [18]. The last part of the questionnaire involved the assessment of the nine body regions (neck, shoulders, elbows, wrists/hands, upper back, lower back, hips/buttocks, knees, and ankles/feet) marked in the picture to help nurses understand the appointed areas.

The participants were required to complete the questionnaire independently and anonymously to ensure that the data reflected the actual situation. We distributed 230 questionnaires to the nurses and received 205 (89%) answered questionnaires. The questionnaire response rate was higher than the minimum rate (70%) recommended by the National Institute for Occupational Safety and Health for epidemiological studies [19]. After filtering, a total of 189 questionnaires were retained for the study.

2.4 Data analysis

SPSS version 19.0 [20] was used to conduct the statistical analysis. Chi-square tests were performed to assess the associations between sleep problems, psychological problems, and musculoskeletal pain symptoms (yes or no). Binary logistic regression analysis was conducted to identify the primary factors affecting the prevalence of musculoskeletal pain. The odds ratio (OR) of chi-square and logistic regression can determine whether the factors’ changes are synergistic (>1) or antagonistic (<1). A P-value <0.05 was considered significant, and only associations with significance were reported.

3 Results

3.1 Statistics of general characteristics

Questionnaires were collected 3 days after distribution. The demographic data of the study sample, including age (18–58 years, mean: 29.8 years), assigned ward, marital status, and BMI (mean: 21.6), were presented. In the study conducted by the World Health Organization in the Asian population, the standard BMI was between 18.5 kg/m² and 23 kg/m², and a BMI of >23 kg/m² was considered overweight. More than 50% of the participants had normal interregional BMI. Other data about our samples are presented in Table 1.

Table 1
Demographics of the participants (N = 189)

Variable N(%)

Age

<25 75 (39.7)

26-35 72 (38.1)

36-45 26 (13.8)

>45 16 (8.4)

BMI

<18.5 28 (14.9)

18.5-23 102 (54.0)

>23 59 (31.2)

Martial statues

Unmarried 91 (48.1)

Married 98 (51.9)

Occupational ward

Outpatient service 11 (5.8)

Ward 111 (58.7)

Operation ward 14 (7.4)

Emergency ward 15 (7.9)

Intensive care unit 22 (11.7)

Others 16 (8.5)

Nursing experience

1-5 years 88 (46.6)

6-10 years 44 (23.3)

11-20 years 34 (17.9)

>20 years 23 (12.2)

Variable	N(%)
Age
<25	75 (39.7)
26-35	72 (38.1)
36-45	26 (13.8)
>45	16 (8.4)
BMI
<18.5	28 (14.9)
18.5-23	102 (54.0)
>23	59 (31.2)
Martial statues
Unmarried	91 (48.1)
Married	98 (51.9)
Occupational ward
Outpatient service	11 (5.8)
Ward	111 (58.7)
Operation ward	14 (7.4)
Emergency ward	15 (7.9)
Intensive care unit	22 (11.7)
Others	16 (8.5)
Nursing experience
1-5 years	88 (46.6)
6-10 years	44 (23.3)
11-20 years	34 (17.9)
>20 years	23 (12.2)

3.2 Prevalence of musculoskeletal pain

A total of 189 available nurses were included in the study. The most commonly reported musculoskeletal pain symptom was observed in the lower back, with an overall prevalence of 172 (91.0%). This was followed by musculoskeletal pain in the neck (170, 89.9%), shoulders (152, 80.4%), and upper back (149, 78.8%). Pain in these four body regions was more frequent than that in the other five regions. Pain in the hips/buttocks was the least reported pain (54, 28.6%). The percentage of musculoskeletal pain symptoms in all nine body regions is shown in Table 2.

Table 2
Number and rate of the nurses with MSDs (N = 189)

Body regions MSD symptoms N (%)

Lower back 172 (91.0)

Neck 170 (89.9)

Shoulders 152 (80.4)

Upper back 149 (78.8)

Wrists/hands 111 (58.7)

Knees 106 (56.1)

Ankles-feet 86 (45.5)

Elbows 69 (36.5)

Hips/buttocks 54 (28.6)

Body regions	MSD symptoms N (%)
Lower back	172 (91.0)
Neck	170 (89.9)
Shoulders	152 (80.4)
Upper back	149 (78.8)
Wrists/hands	111 (58.7)
Knees	106 (56.1)
Ankles-feet	86 (45.5)
Elbows	69 (36.5)
Hips/buttocks	54 (28.6)

3.3 Association of musculoskeletal pain symptom with sleep problems

The three groups of sleep durations, i.e., 6–8 hours, <6 hours and >8 hours a day, varied significantly based on the frequency of musculoskeletal pain in different body regions (as shown in Table 3 and Fig. 1). The frequency of neck musculoskeletal pain, upper back musculoskeletal pain, knee musculoskeletal pain, and ankle/foot musculoskeletal pain were 12.35 times (p = 0.002, OR = 12.35, confidence interval [CI] = 1.608–95.328), 4.12 (p = 0.002, OR = 4.12, CI = 1.611–1.467) times, 2.55 (p = 0.004, OR = 2.55, CI = 1.346–4.814) times, and 2.19 (p = 0.012, OR = 2.19, CI = 1.179–4.050) times higher in the group with a sleep duration of <6 hours a day than in the group a with a sleep duration of 6–8 hours. Relatively, nurses who slept >8 hours a day had 1.10 (p = 0.038, OR = 1.10, CI = 0.851–5.175) times higher risk of developing wrist/hand musculoskeletal pain than those who slept 6–8 hours. However, little difference was observed in the musculoskeletal pain of the shoulders, elbow shoulders, lower back, and hips/buttocks between the three groups.

Table 3
Sleep problems associated with the presence of MSDs at multiple body regions

Body regions Duration of sleep¹ Sleep onset time² Quality of sleep³

OR p value CI (95%) OR p value CI (95%) OR p value CI (95%)

Neck 1 reference 1 reference 1 reference

12.35 0.002 1.608-95.328 3.57 0.039 0.998-12.815 3.125 0.028 1.101-8.870

1.47 0.719 0.174-12.593 * * * 35.8 <0.001 4.367-294.040

Shoulders 1 reference 1 reference 1 reference

2.70 0.082 0.930-3.261 2.25 0.062 0.947-5.344 2.96 0.017 1.190-7.372

* * * 2.11 0.250 0.578-7.716 5.39 <0.001 2.087-13.922

Elbows 1 reference 1 reference 1 reference

1.10 0.082 0.930-3.261 1.46 0.251 0.765-2.776 1.07 0.884 0.452-2.516

1.74 0.894 0.260-4.674 0.71 0.507 0.255-1.967 1.07 0.878 0.466-2.440

Wrists/hands 1 reference 1 reference 1 reference

1.74 0.264 0.776-2.633 1.29 0.434 0.679-2.465 1.63 0.251 0.706-3.764

1.10 0.038 0.851-58.175 0.92 0.851 0.363-2.307 1.15 0.737 0.517-2.540

Upper back 1 reference 1 reference 1 reference

4.12 0.002 1.611-10.467 3.45 0.008 1.334-8.864 1.85 0.167 0.768-4.491

0.79 0.775 0.187-3.379 1.235 0.684 0.422-3.715 4.76 0.001 1.834-12.390

Lower back 1 reference 1 reference 1 reference

1.47 0.055 0.530-4.057 2.56 0.145 0.694-9.476 2.26 0.154 0.722-7.074

1.08 0.942 0.125-9.375 1.30 0.740 0.271-6.289 7.26 0.002 1.754-30.042

Hips/buttocks 1 reference 1 reference 1 reference

1.45 0.273 0.744-2.835 1.10 0.980 0.504-2.019 2.42 0.104 0.818-7.138

1.52 0.571 0.355-6.490 0.93 0.882 0.330-2.590 2.9 0.040 1.016-8.275

Knees 1 reference 1 reference 1 reference

2.55 0.004 1.346-4.814 1.46 0.254 0.764-2.766 1.81 0.161 0.786-4.167

2.27 0.251 0.541-9.562 0.718 0.474 0.284-1.799 2.33 0.037 1.041-5.248

Ankles/feet 1 reference 1 reference 1 reference

2.19 0.012 1.179-4.050 1.41 0.278 0.754-2.670 1.46 0.387 0.616-3.479

3.46 0.076 0.818-14.556 1.41 0.456 0.564-3.568 2.45 0.032 1.068-5.652

Body regions	Duration of sleep¹	Sleep onset time²	Quality of sleep³
Neck	1	reference		1	reference		1	reference
	12.35	0.002	1.608-95.328	3.57	0.039	0.998-12.815	3.125	0.028	1.101-8.870
	1.47	0.719	0.174-12.593	*	*	*	35.8	<0.001	4.367-294.040
Shoulders	1	reference		1	reference		1	reference
	2.70	0.082	0.930-3.261	2.25	0.062	0.947-5.344	2.96	0.017	1.190-7.372
	*	*	*	2.11	0.250	0.578-7.716	5.39	<0.001	2.087-13.922
Elbows	1	reference		1	reference		1	reference
	1.10	0.082	0.930-3.261	1.46	0.251	0.765-2.776	1.07	0.884	0.452-2.516
	1.74	0.894	0.260-4.674	0.71	0.507	0.255-1.967	1.07	0.878	0.466-2.440
Wrists/hands	1	reference		1	reference		1	reference
	1.74	0.264	0.776-2.633	1.29	0.434	0.679-2.465	1.63	0.251	0.706-3.764
	1.10	0.038	0.851-58.175	0.92	0.851	0.363-2.307	1.15	0.737	0.517-2.540
Upper back	1	reference		1	reference		1	reference
	4.12	0.002	1.611-10.467	3.45	0.008	1.334-8.864	1.85	0.167	0.768-4.491
	0.79	0.775	0.187-3.379	1.235	0.684	0.422-3.715	4.76	0.001	1.834-12.390
Lower back	1	reference		1	reference		1	reference
	1.47	0.055	0.530-4.057	2.56	0.145	0.694-9.476	2.26	0.154	0.722-7.074
	1.08	0.942	0.125-9.375	1.30	0.740	0.271-6.289	7.26	0.002	1.754-30.042
Hips/buttocks	1	reference		1	reference		1	reference
	1.45	0.273	0.744-2.835	1.10	0.980	0.504-2.019	2.42	0.104	0.818-7.138
	1.52	0.571	0.355-6.490	0.93	0.882	0.330-2.590	2.9	0.040	1.016-8.275
Knees	1	reference		1	reference		1	reference
	2.55	0.004	1.346-4.814	1.46	0.254	0.764-2.766	1.81	0.161	0.786-4.167
	2.27	0.251	0.541-9.562	0.718	0.474	0.284-1.799	2.33	0.037	1.041-5.248
Ankles/feet	1	reference		1	reference		1	reference
	2.19	0.012	1.179-4.050	1.41	0.278	0.754-2.670	1.46	0.387	0.616-3.479
	3.46	0.076	0.818-14.556	1.41	0.456	0.564-3.568	2.45	0.032	1.068-5.652

*Whole participant showed MSDs symptom; ¹Three different groups of duration of sleep: reference is the 6 to 8 hours, the other two are less than 6 hours and more than 8 hours; ²Three different groups of sleep onset time: reference is between 9 and 11 PM, between 11 PM and 12 PM and after 12 PM; ³Three different groups of sleep quality: reference is high, intermediate and low; ⁴Differences between groups evaluated using the Chi-square test.

Fig. 1

Prevalence of MSDs by body regions at different sleep problems levels.

Based on the sleep onset time, the participants were divided into three groups, i.e., 9–11 pm group, 11 pm–12 am group, and after 12 am group, which only showed remarkable differences in the prevalence of neck musculoskeletal pain and upper back musculoskeletal pain. Sleep onset time at 11 pm–12 am was associated with a 3.75-fold higher risk (p = 0.039, OR = 3.57, CI = 0.998–12.815) of developing neck musculoskeletal pain, while sleep onset time at 9–11 pm was associated with a 3.45-fold higher risk (p = 0.008, OR = 3.45, CI = 1.334–8.864) of developing upper back musculoskeletal pain.

In terms of sleep quality (i.e., high, intermediate, and low), the following six regions were significantly affected: neck, shoulder, upper back, lower back, hips/buttocks, and knees. Low sleep quality was associated with a 35.8-fold (p < 0.001, OR = 35.8, CI = 4.367–294.040) higher risk of developing neck musculoskeletal pain, 5.39-fold (p < 0.001, OR = 5.39, CI = 2.087–13.922) higher risk of developing shoulder musculoskeletal pain, 4.76-fold (p = 0.001, OR = 4.76, CI = 1.834-12.390) higher risk of developing upper back musculoskeletal pain, 7.26-fold (p = 0.002, OR = 4.76, CI = 1.834–12.390) higher risk of developing lower back musculoskeletal pain, 2.9-fold (p = 0.040, OR = 2.9, CI = 1.016–8.275) higher risk of developing hip/buttock musculoskeletal pain, and 2.33-fold (p = 0.037, OR = 2.33, CI = 1.041–5.248) higher risk of developing musculoskeletal pain in the knees compared with high sleep quality. Meanwhile, intermediate sleep quality was associated with a 3.125-fold (p = 0.028, OR = 3.125, CI = 1.101–8.870) risk of developing neck musculoskeletal pain compared with high sleep quality and 2.96-fold higher risk (p = 0.017, OR = 2.96, CI = 1.190-7.372) of developing shoulder musculoskeletal pain.

3.4 Association of musculoskeletal pain symptoms with factors of psychology problems

Compared with the previous two factors, the association between psychological problems and musculoskeletal pain symptoms was less significant (as shown in Table 4 and Fig. 2). The levels of occupational pride, stress, and family support were divided into three groups: high, intermediate, and low. Results indicated that nurses with low occupational pride were 8.80 times (p = 0.004, OR = 8.80, CI = 1.602–48.386) more likely to experience neck musculoskeletal pain and 2.48 times (p = 0.039, OR = 2.48, CI = 1.306–5.950) more likely to experience wrist/hand musculoskeletal pain than those with high occupational pride. Relatively, intermediate stress was associated with a 0.376-fold higher risk (p = 0.035, OR = 0.376, CI = 0.148–0.951) of hip/buttock musculoskeletal pain than low stress, while high stress was associated with a 2.897-fold higher risk (p = 0.027, OR = 2.897, CI = 1.099-7.637) of upper back musculoskeletal pain than low stress. Moreover, occupational stress had a slight effect on other body regions, while the effect of family support was not remarkable according to the result.

Table 4
Psychology problems associated with the presence of MSDs at multiple body regions

Body regions Occupational pride¹ Stress² Family support³

OR p value CI (95%) OR p value CI (95%) OR p value CI (95%)

Neck 1 reference 1 reference 1 reference

1.19 0.760 0.380-3.762 0.835 0.774 0.244-2.858 0.742 0.576 0.260-2.117

8.80 0.004 1.602-48.386 3 0.123 0.702-12.824 1.230 0.808 0.232-6.509

Shoulders 1 reference 1 reference 1 reference

0.63 0.405 0.211-1.880 0.421 0.140 0.130-1.361 0.807 0.598 0.364-1.790

1.28 0.666 0.410-4.039 0.751 0.639 0.227-2.485 0.960 0.945 0.303-3.046

Elbows 1 reference 1 reference 1 reference

2.55 0.064 0.930-6.997 0.524 0.127 0.227-1.210 1.791 0.087 0.916-3.505

2.18 0.122 0.799-5.979 0.590 0.223 0.252-1.383 1.737 0.244 0.683-4.418

Wrists/hands 1 reference 1 reference 1 reference

1.82 0.177 0.760-4.353 0.597 0.242 0.251-1.421 1.286 0.439 0.679-2.438

2.48 0.039 1.036-5.950 0.911 0.831 0.387-2.145 0.709 0.451 0.289-1.737

Upper back 1 reference 1 reference 1 reference

0.967 0.947 0.357-2.615 1.455 0.424 0.579-3.659 1.003 0.994 0.473-2.127

1.79 0.634 0.634-5.079 2.897 0.027 1.099-7.637 1.659 0.408 0.496-5.547

Lower back 1 reference 1 reference 1 reference

0.47 0.336 0.097-2.259 1.053 0.935 0.299-3.717 0.677 0.494 0.220-2.082

1.51 0.638 0.263-8.780 3 0.123 0.702-12.824 1.008 0.993 0.183-5.542

Hips/buttocks 1 reference 1 reference reference

1.03 0.974 0.382-2.798 0.376 0.035 0.148-0.951 0.986 0.970 0.486-2.002

1.44 0.455 0.548-3.819 0.778 0.563 0.332-1.824 1.872 0.188 0.732-4.785

Knees 1 reference 1 reference 1 reference

0.58 0.236 0.240-1.426 0.718 0.441 0.309-1.669 1.095 0.779 0.582-2.059

0.76 0.547 0.314-1.850 1.510 0.332 0.655-3.482 1.014 0.977 0.413-2.490

Ankles/feet 1 reference 1 reference 1 reference

1.19 0.693 0.495-2.881 0.703 0.413 0.302-1.639 1.040 0.903 0.554-1.952

1.51 0.354 0.631-3.608 1.042 0.992 0.458-2.372 1.145 0.767 0.468-2.804

Body regions	Occupational pride¹	Stress²	Family support³
Neck	1	reference		1	reference		1	reference
	1.19	0.760	0.380-3.762	0.835	0.774	0.244-2.858	0.742	0.576	0.260-2.117
	8.80	0.004	1.602-48.386	3	0.123	0.702-12.824	1.230	0.808	0.232-6.509
Shoulders	1	reference		1	reference		1	reference
	0.63	0.405	0.211-1.880	0.421	0.140	0.130-1.361	0.807	0.598	0.364-1.790
	1.28	0.666	0.410-4.039	0.751	0.639	0.227-2.485	0.960	0.945	0.303-3.046
Elbows	1	reference		1	reference		1	reference
	2.55	0.064	0.930-6.997	0.524	0.127	0.227-1.210	1.791	0.087	0.916-3.505
	2.18	0.122	0.799-5.979	0.590	0.223	0.252-1.383	1.737	0.244	0.683-4.418
Wrists/hands	1	reference		1	reference		1	reference
	1.82	0.177	0.760-4.353	0.597	0.242	0.251-1.421	1.286	0.439	0.679-2.438
	2.48	0.039	1.036-5.950	0.911	0.831	0.387-2.145	0.709	0.451	0.289-1.737
Upper back	1	reference		1	reference		1	reference
	0.967	0.947	0.357-2.615	1.455	0.424	0.579-3.659	1.003	0.994	0.473-2.127
	1.79	0.634	0.634-5.079	2.897	0.027	1.099-7.637	1.659	0.408	0.496-5.547
Lower back	1	reference		1	reference		1	reference
	0.47	0.336	0.097-2.259	1.053	0.935	0.299-3.717	0.677	0.494	0.220-2.082
	1.51	0.638	0.263-8.780	3	0.123	0.702-12.824	1.008	0.993	0.183-5.542
Hips/buttocks	1	reference		1	reference			reference
	1.03	0.974	0.382-2.798	0.376	0.035	0.148-0.951	0.986	0.970	0.486-2.002
	1.44	0.455	0.548-3.819	0.778	0.563	0.332-1.824	1.872	0.188	0.732-4.785
Knees	1	reference		1	reference		1	reference
	0.58	0.236	0.240-1.426	0.718	0.441	0.309-1.669	1.095	0.779	0.582-2.059
	0.76	0.547	0.314-1.850	1.510	0.332	0.655-3.482	1.014	0.977	0.413-2.490
Ankles/feet	1	reference		1	reference		1	reference
	1.19	0.693	0.495-2.881	0.703	0.413	0.302-1.639	1.040	0.903	0.554-1.952
	1.51	0.354	0.631-3.608	1.042	0.992	0.458-2.372	1.145	0.767	0.468-2.804

¹The three levels of occupational pride: reference is high, intermediate and low; ²The three levels of the stress: reference is high, intermediate and low; ³The three levels of family support: reference is high, intermediate and low; ⁴Differences between groups evaluated using the Chi-square test.

Fig. 2

Prevalence of MSDs by body regions at different psychological levels.

3.5 Risk factor selection by binary logistic regression analysis

Binary logistic regression analysis showed the most influential factors in the eight body regions, excluding wrists/hands. In the regression model, as shown in Table 5, sleep quality was the primary factor contributing to the occurrence of musculoskeletal pain in the neck, shoulders, and upper back (p_neck = 0.005, p_shoulders < 0.001, p_lower back = 0.003). The duration of sleep was observed only in the shoulder model (p < 0.001), and the sleep onset time was the same in the upper back model (p < 0.001).

Table 5
Binary logistic regression of risk factors

Body regions Factors P-value CI (95%) OR

Neck Sleep quality 0.005 0.904-7.620 2.625

3.525-242.721 29.250

Shoulders Sleep quality <0.001 0.156-1.406 0.469

1.018-8.454 5.006

Duration of sleep <0.001 1.691-20.537 2.933

5.893

Upper back Sleep quality 0.003 0.518-3.374 1.322

1.899-21.258 6.353

Sleep onset time <0.001 1.209-10.015 3.479

0.116-1.704 0.444

Body regions	Factors	P-value	CI (95%)	OR
Neck	Sleep quality	0.005	0.904-7.620	2.625
			3.525-242.721	29.250
Shoulders	Sleep quality	<0.001	0.156-1.406	0.469
			1.018-8.454	5.006
	Duration of sleep	<0.001	1.691-20.537	2.933
				5.893
Upper back	Sleep quality	0.003	0.518-3.374	1.322
			1.899-21.258	6.353
	Sleep onset time	<0.001	1.209-10.015	3.479
			0.116-1.704	0.444

*No variable entry the logistic regression equation as important influential factors.

4 Discussion

4.1 Prevalence of musculoskeletal pain in nurses

The prevalence of musculoskeletal pain among nurses is higher than expected. The trend of musculoskeletal pain in nurses has either emerged or even deteriorated in both developed and developing countries.

According to an investigation on the trend of musculoskeletal pain in nursing personnel in China [21], the prevalence rates of musculoskeletal pain in the lower back, neck, shoulder, and upper back were 56.7%, 42.8%, and 38.9%, respectively. However, the rates in our study were obviously higher than those reported in 2004, which were 91.0% for lower back, 89.9% for neck, 80.4% for shoulder, and 78.8% for upper back, indicating that the measures taken for musculoskeletal pain have not achieved great progress. In clinical practice, nursing interventions primarily focus on changing the shift frequency to help nurses prevent musculoskeletal pain. Takahashi et al. [22] found that inappropriate shift work can lead to sleep problems among nurses and induce musculoskeletal pain. Moreover, rapidly aging societies may limit the effectiveness of such preventive interventions.

A longitudinal comparison of musculoskeletal pain among nurses in different countries is discussed further. Studies have shown that the prevalence of musculoskeletal pain among clinical nurses has been increasing in recent years, and the risk in developing countries is higher than that in developed countries [14]. The prevalence rates of musculoskeletal pain among nurses were 69% in the United States, 74.9% in Brazil [23], 88.8% in Turkey [24], 70.8% in South Korea [25], and 61% in Iran [26]. Due to the differences in the levels of economic and medical development in various countries, the health management systems, human resources, nursing work content, working conditions, and geographical environments vary. The prevalence of musculoskeletal pain is inconsistent, and the location of the disease differs. Chinese scholars have reported that the prevalence rate of musculoskeletal pain among healthcare workers in China is 84%–87.46%, which is relatively high. The main reason for this difference is that with the continuous development of medical technology and the improvement in people’s healthcare needs, the load of medical work is constantly increasing every year, and nursing shortage occurs, resulting in heavy work, high work pressure, and high risk of musculoskeletal pain in nurses. The organizational management of relevant support facilities and protection training programs remains inaccurate, leading to work overload for a long-term period and the high prevalence of musculoskeletal pain among nurses. Some regulations are aimed at preventing the occurrence of musculoskeletal pain among healthcare workers in the European Union [27] and the United Kingdom [28].

4.2 Risk factors of sleep problems and musculoskeletal pain among nurses

The chi-square test showed that sleep quality had a more significant impact on musculoskeletal pain compared with sleep duration and sleep onset time, especially pain in the neck, shoulders, upper back, and lower back. Furthermore, through a comparison with the other factors in this study, sleep quality acts as the main function in the binary logistic model of the neck, shoulder, and upper back. The binary logistic results showed that the different factors were not in the same status when analyzing different body regions. The result of the chi-square test on the three factors of sleep problems is consistent with that reported in other studies [22]. In addition, the effect of sleep quality is greater in the neck, shoulders, and upper back. One of the body regions that was severely influenced by sleep problems was the neck. Improvement in sleep quality could lead to a reduction in the severity of musculoskeletal pain. Taking regular naps and establishing regular waking time and sleep time would improve sleep quality.

Based on the results of previous studies on sleep area, non-restorative sleep is one of the reasons for the occurrence of pain, thus requiring a deeper understanding of the link between these two factors. Some studies have attempted to explain the mechanism by which sleep accelerates pain the next day. Poor sleep quality may not relax the muscles at night, causing disturbance in the blood circulation [29]. Sleep deprivation induces hyperalgesia by decreasing the descending pain-suppressing activity and increasing the descending pain-facilitating activity [30], as well as inducing agitation, a high stress response, and unpleasant emotional and psychological reactions in patients, and even leads to more severe complications [31]. Sleep deprivation among medical staff may cause sleepiness while working night shifts, sudden insomnia and tardiness. The biological clock plays an important role in human health, and disruption of the biological clock has adverse effects on the body [32]. Nurses often work night shifts, which can lead to disturbance of the biological clock, affecting their sleep, diet, family life, and social activities and causing changes in the endocrine system. In addition, involuntary neurological symptoms such as immunosuppression, colds, gastrointestinal infections, and allergies can also occur. Staying up late for long periods leads to insomnia, forgetfulness, irritability, anxiety, and other neurological and psychiatric symptoms. This study showed that nurses with irregular work schedules, who frequently work night shifts, or who stay up late had the highest prevalence of WRMSD.

Following regular sleeping patterns to improve the sleep quality can help nurses relieve pain. Healthy sleep requires good sleep quality, reasonable time to fall asleep, and proper sleep duration, which can help reduce the development of musculoskeletal pain. Good sleep habits, proper exercise, avoidance of alcohol and caffeine, and attention to the details of sleep habits can improve the sleep quality. In addition, it is necessary to establish a reasonable shift system, and nurses who work night shifts should live in an area that is close to the hospital that they are working in to avoid further delay in sleeping.

4.3 Psychological factors that increase the risk of musculoskeletal pain among nurses

In the last 10 years, an increasing number of researchers have reported an association between psychosocial factors and musculoskeletal pain. A study by the National Institute for Occupational Safety in the United States suggested a correlation between psychosocial factors and the occurrence of occupational musculoskeletal injuries [33]. Dinora et al. [34] conducted a meta-analysis of 24 articles on psychosocial risk factors of hospital nurses and showed that the psychosocial risk factors of nurses in the workplace were related to WRMSDs. This result is consistent with the conclusions of other researchers [35, 36]; i.e. psychosocial factors are important factors influencing WRMSDs. This study showed that among the psychological factors, professional pride and stress had significant effects on pain, while family support had no significant effect on pain.

To determine an efficient measurement that can help decrease the risk, some studies attempted to explain the mechanism of stress with the indication that the interaction between stress and musculoskeletal pain is complex, contributing to the development of musculoskeletal pain [37]. Pain conduction starts from the spinal cord and continues to the brain center. Human pain sensation is the result of the combined action of many ascending and descending facilitation and inhibition pathways [38]. Persistent stress can induce, sustain, and intensify pain sensitivity, thereby modulating pain perception [39]. Chronic pain triggers dysfunction in the pain-related regions of the central nervous system such as the insula, limbic system, and anterior cingulate gyrus. These areas have been related to people’s psychological emotions, which shows that chronic pain not only is a complex process of central lesions but also causes changes in psychological emotions. Mindfulness therapy [40], founded by Dr. Kabat-Zinn in 1979, is effective in treating chronic pain. Mindfulness therapy can change a patient’s perception of pain, strengthen the acceptance of pain sensation, and improve physical function by reducing psychological pressure. In addition, because of the differences in male and female psychology, the level of musculoskeletal pain also differs. The difference between women and men in terms of the level of musculoskeletal pain is mainly associated with the inherent psychological characteristic because women are passive when receiving interventions.

Therefore, nursing managers should pay more attention to decreasing the prevalence of musculoskeletal pain among nurses, reducing the known occupational risk factors from a management perspective, focusing on the mental health of the medical staff, helping them relieve psychological pressure, improving professional pride, and striving to create a safe and harmonious cultural environment.

4.4 Limitations of the study

It is necessary to elucidate the findings of this study with a certain degree of caution. This conservatism is due to the limited sample size owing to the demographic characteristics or musculoskeletal pain classification. The possible selection bias cannot be dismissed because our investigation excluded nursing students, retired nurses, male nurses, and nurses in common class hospitals. Sometimes, nursing students undertake the most physical work tasks, and some nurses resign due to serious musculoskeletal pain. Moreover, in some countries, male nurses account for a considerable proportion of nursing staff, and the condition of musculoskeletal pain among nurses may vary in different classes of hospitals. In addition, the effect of smoking, alcohol consumption, and being overweight on musculoskeletal pain in nurses was not addressed in this study. Nurses’ educational background and lack of formal on-the-job training are both factors that should be considered in future studies. The results may also be influenced by recall bias since the data analysis was based on self-reported questionnaires. Research efforts using more objective measures to assess musculoskeletal pain in nursing personnel, for example, widely accepted clinical tests [36] or approaches utilizing electromyography, would be required to verify the results. Further longitudinal epidemiological research should be conducted to identify the common trajectories.

5 Conclusions

This study evaluated the prevalence of musculoskeletal pain and the associated risk factors among Chinese female nursing personnel, i.e. sleep and psychological problems. Compared with other body regions, musculoskeletal pain in the lower back, neck, and shoulders requires more attention and preventive interventions. Sleep problems may explain the casual musculoskeletal pain in the neck, shoulders, and upper back. Psychological factors such as occupational pride and job stress also have a potential influence. To help alleviate the burden of musculoskeletal pain, great measures should be taken to improve work organizations, create good work schedules, and ensure psychological guidance. Special efforts should be made to shift the workday system of the nursing group because of the strong correlation between sleep problems and pain. Incentives other than penalty mechanisms should be considered seriously in nursing to boost occupational pride and relieve job stress. The multifactorial course for musculoskeletal pain highlights the need for research on preventive interventions from organizational and psychosocial considerations.

Footnotes

Acknowledgments

The authors are grateful to all the nursing personnel who participated in this study and to the specific hospital in Beijing for their assistance in conducting this study. The authors would also like to express their gratitude to the University of Science and Technology Beijing for providing administrative and technical support.

Conflict of interest

None of the authors have any conflicts of interest to declare.

Funding

The authors do not have any funding to disclose.

Ethical considerations

The study was approved by the Ethical Review Committee of the university.

Informed consent

Written informed consent was obtained from all participants.

References

2020 Statistical Bulletin on the Development of my country’s Health and Wellness[homepage on the Internet]. c2021[updated 2021 July 22; cited 2022 Mar 1]. Available from: http://www.gov.cn/guoqing/2021-07/22/content_5626526.htm

Nurses [homepage on the Internet]. c2020[updated 2020 Dec 31; cited 2022 Mar 1]. Available from: https://data.oecd.org/healthres/nurses.htm

Ministry of Human Resources and Social Security of China [homepage on the Internet]. c2020[updated 2020 Sep 17; cited 2022 Mar 1]. Available from: http://www.mohrss.gov.cn/

Yang

, Lu

, Zeng

, Wang

, Li

. Prevalence and Risk Factors of Work-Related Musculoskeletal Disorders Among Intensive Care Unit Nurses in China. Work Heal Saf. 2019;67(6):275–87.

Thinkhamrop

, Sawaengdee

, Tangcharoensathien

, Theerawit

, Laohasiriwong

, Saengsuwan

, et al. Burden of musculoskeletal disorders among registered nurses: Evidence from the Thai nurse cohort study. BMC Nurs. 2017;16(68):1–9.

Tariah

, Nafai

, Alajmi

, Almutairi

, Alanazi

. Work-related musculoskeletal disorders in nurses working in the Kingdom of Saudi Arabia. Work. 2020;65(2):421–8.

Nourollahi

, Afshari

, Dianat

. Awkward trunk postures and their relationship with low back pain in hospital nurses. Work. 2018;59:317–23.

Sun

, Tian

, Zhang

, Tang

, He

. The health status and influencing factors analysis of nurses’ work-related musculoskeletal disease. J Nurs Adm. 2021;21(5):328.

Samaei

, Mostafaee

, Jafarpoor

, Hosseinabadi

. Effects of patient-handling and individual factors on the prevalence of low back pain among nursing personnel. Work. 2017;56:551–61.

10.

Wang

, Cui

, He

, Xu

, Yuan

, Jin

, et al. Work-related musculoskeletal disorders and risk factors among Chinese medical staff of obstetrics and gynecology. Int J Environ Res Public Health. 2017;14(6):562.

11.

Akodu

, Ashalejo

. Work-related musculoskeletal disorders and work ability among hospital nurses. J Taibah Univ Med Sci. 2019;252–261.

12.

Darvishi

, Khotanlou

, Khoubi

, Giahi

, Mahdavi

. Prediction Effects of Personal, Psychosocial, and Occupational Risk Factors on Low Back Pain Severity Using Artificial Neural Networks Approach in Industrial Workers. J Manipulative Physiol Ther. 2017;40(7):486–93.

13.

Cheung

, Szeto

, Lai

GKB

, Ching

SSY

. Prevalence of and factors associated with work-related musculoskeletal symptoms in nursing assistants working in nursing homes. Int J Environ Res Public Health. 2018;15(2):265.

14.

Bakola

, Zyga

, Stergioulas

, Kipreos

, Panoutsopoulos

. Musculoskeletal Problems Among Greek Perioperative Nurses in Regional Hospitals in Southern Peloponnese: Musculoskeletal Problems in Perioperative Nurses. Adv Exp Med Biol. 2017;989:21–37.

15.

Yan

, Li

, Zhang

, Yang

, Huang

, Wang

, et al. Prevalence of Work-Related Musculoskeletal Disorders in the Nurses Working in Hospitals of Xinjiang Uygur Autonomous Region. Pain Res Manag. 2017:2017:1–7.

16.

Heidari

, Borujeni

, Rezaei

, Abyaneh

. Work-related musculoskeletal disorders and their associated factors in nurses: A cross-sectional study in Iran. Malaysian J Med Sci. 2019;26(2):122–130.

17.

Kuorinka

, Jonsson

, Kilbom

, Vinterberg

, Biering-Sørensen

, Andersson

, et al. Standardised Nordic questionnaires for the analysis of musculoskeletal symptoms. Appl Ergon. 1987;18(3):233–7.

18.

Bao

, Winkel

, Shahnavaz

. Prevalence of musculoskeletal disorders at workplaces in the people’s republic of China. Int J Occup Saf Ergon. 2000;6(4):557–74.

19.

. Musculoskeletal disorders and workplace factors: a critical review of epidemiologic evidence for work-related musculoskeletal disorders of the neck upper extremity and low back NIOSH CDC (Centers for Disease Control and Prevention) 1997.

20.

SPSS for Microsoft [homepage on the Internet]. c2022[cited 2022 Mar 1]. Available from: https://www.ibm.com/cn-zh/analytics/spss-statistics-software

21.

Smith

, Wei

, Kang

, Wang

. Musculoskeletal disorders among professional nurses in mainland China. J Prof Nurs. 2004;20(6):390–5.

22.

Takahashi

, Iwakiri

, Sotoyama

, Hirata

, Hisanaga

. Musculoskeletal pain and night-shift naps in nursing home care workers. Occup Med (Chic Ill). 2009;59(3):197–200.

23.

Santos

HEC Dos

, Marziale

MHP

, Felli

VEA

. Presenteeism and musculoskeletal symptoms among nursing professionals. Rev Lat Am Enfermagem. 2018;26:e3006.

24.

Yilmaz

, Isik Andsoy

. Musculoskeletal system disorders among surgical nurses related to the health industry in northwestern Turkey: a cross-sectional study. Int J Occup Saf Ergon. 2021;1–16.

25.

Ryu

, Ye

, Yi

, Kim

. Risk factors of musculoskeletal symptoms in university hospital nurses. Ann Occup Environ Med. 2014;26(1):47.

26.

Soroush

, Shamsi

, Izadi

, Heydarpour

, Samadzadeh

, Shahmohammadi

. Musculoskeletal disorders as common problems among iranian nurses: A systematic review and meta-analysis study. Int J Prev Med. 2018;9:27.

27.

Hignett

, Fray

, Rossi

, Tamminen-Peter

, Hermann

, Lomi

, et al. Implementation of the Manual Handling Directive in the healthcare industry in the European Union for patient handling tasks. Int J Ind Ergon. 2007;37(5):415–23.

28.

The Manual Handling Operations Regulations 1992 No 2793. [homepage on the Internet]. c2022[cited 2022 Mar 1]. Available from: https://www.legislation.gov.uk/uksi/1992/2793/made

29.

Cheung

, Yuen

, Wong

GTC

, Choi

. The effect of sleep deprivation and disruption on DNA damage and health of doctors. Anaesthesia. 2019;74(4):434–440.

30.

Mills

, Di Pietro

, Alshelh

, Peck

, Murray

, Vickers

, et al. Brainstem pain-control circuitry connectivity in chronic neuropathic pain. J Neurosci. 2018;38(2):465–73.

31.

Lamon

, Morabito

, Arentson-Lantz

, Knowles

, Vincent

, Condo

, et al. The effect of acute sleep deprivation on skeletal muscle protein synthesis and the hormonal environment. Physiol Rep. 2021;9(1):e14660.

32.

Zisapel

. New perspectives on the role of melatonin in human sleep, circadian rhythms and their regulation. Br J Pharmacol. 2018;42(13):3190–3199.

33.

Halford

, Cohen

. Technology use and psychosocial factors in the self-reporting of musculoskeletal disorder symptoms in call center workers. J Safety Res. 2013;34(2):167–73.

34.

Bernal

, Campos-Serna

, Tobias

, Vargas-Prada

, Benavides

, Serra

. Work-related psychosocial risk factors and musculoskeletal disorders in hospital nurses and nursing aides: A systematic review and meta-analysis. Int J Nurs Stud. 2015;52(2):635–648.

35.

Abdul Rahman

, Abdul-Mumin

, Naing

. Psychosocial factors, musculoskeletal disorders and work-related fatigue amongst nurses in Brunei: structural equation model approach. Int Emerg Nurs. 2017;34:17–22.

36.

Yan

, Yang

, Zhang

, Li

, Huang

, Wang

, et al. Correlation analysis between work-related musculoskeletal disorders and the nursing practice environment, quality of life, and social support in the nursing professionals. Med (United States). 2018;97(9):e26.

37.

Herin

, Paris

, Levant

, Vignaud

, Sobaszek

, Soulat

. Links between nurses’ organisational work environment and upper limb musculoskeletal symptoms: Independently of effort-reward imbalance! the ORSOSA study. Pain. 2011;152(9):2006–15.

38.

Yam

, Loh

, Tan

, Adam

, Manan

, Basir

. General pathways of pain sensation and the major neurotransmitters involved in pain regulation. Int J Mol Sci. 2018;19(8):2164.

39.

Studer

, Stewart

, Egloff

, et al. Psychosocial stressors and pain sensitivity in chronic pain disorder with somatic and psychological factors (F45.41). Schmerz (Berlin, Germany). 2018;31(1):40–46.

40.

Ruiz-Fernández

, Ortíz-Amo

, Ortega-Galán

ÁM

, Ibáñez-Masero

, Rodríguez-Salvador

M del M

, Ramos-Pichardo

. Mindfulness therapies on health professionals. Int J Ment Health Nurs. 2020.

Do sleep and psychological factors influence musculoskeletal pain among nurses?

Abstract

BACKGROUND:

OBJECTIVE:

METHODS:

RESULTS:

CONCLUSION:

Keywords

1 Introduction

2 Methods

2.1 Participants

2.2 Interview

2.3 Questionnaire

2.4 Data analysis

3 Results

3.1 Statistics of general characteristics

Table 2 Number and rate of the nurses with MSDs (N = 189) Body regions MSD symptoms N (%) Lower back 172 (91.0) Neck 170 (89.9) Shoulders 152 (80.4) Upper back 149 (78.8) Wrists/hands 111 (58.7) Knees 106 (56.1) Ankles-feet 86 (45.5) Elbows 69 (36.5) Hips/buttocks 54 (28.6)

4.1 Prevalence of musculoskeletal pain in nurses

4.2 Risk factors of sleep problems and musculoskeletal pain among nurses

4.3 Psychological factors that increase the risk of musculoskeletal pain among nurses

4.4 Limitations of the study

5 Conclusions

Footnotes

Acknowledgments

Conflict of interest

Funding

Ethical considerations

Informed consent

References

Table 2
Number and rate of the nurses with MSDs (N = 189)

Body regions MSD symptoms N (%)

Lower back 172 (91.0)

Neck 170 (89.9)

Shoulders 152 (80.4)

Upper back 149 (78.8)

Wrists/hands 111 (58.7)

Knees 106 (56.1)

Ankles-feet 86 (45.5)

Elbows 69 (36.5)

Hips/buttocks 54 (28.6)