The prevalence of upper quadrants work-related musculoskeletal disorders and their predictors among registered nurses

2.1 Design and sample

A cross-sectional design was utilized in this study. Approximately 750 registered nurse working full-time from different hospitals in Jordan were invited to participate. The study adopted a sample of convenience that included clusters represented all Jordanian geographical regions. A sample size larger than 500 participants is considered excellent in cross-sectional studies [49].

Jordan is a country in the Middle East and consists of three geographical regions (north, middle and south) with a population distribution of 29%, 61%and 9.5%respectively [50]. Each region has governmental, military, and private hospitals. These hospitals offer services at regional and district levels. These hospitals serve a wide range of patients from a variety of socio-economic status and communities. Based on the geographical population, study paper copy surveys were sent to hospitals nursing wards in each geographical regions with trained research assistants ready to answer participants’ questions. Eligible participants were required to be less than 60 years old and working in shifts for at least three shifts per week for at least one year. Nurses with long-term administration of analgesic medicine, who have a history of psychiatric or congenital disorders, and those who had spine surgery, or major chronic disease that may cause musculoskeletal pain were excluded.

2.2 Procedures

The Institutional Review Board (IRB) at Jordan University of Science and Technology (JUST) reviewed the study and approved the its procedures (approval number 50/117/2018). Participants’ recruitment started in July 2018 and ended in December 2018. All participants signed the IRB approved informed consents and received no compensation for their participation. Study researchers approached 750 nurses representing all Jordanian geographical regions and hospital types.

2.3 Outcome measures

A three-section questionnaire was developed for this study. The sociodemographic section included gender, age, height, weight, smoking habits, self-reported health status, self-reported diet quality, work experience, hospital type, and description of work shifts. The second section collected data on work ergonomics including body postures, use of handling equipment, and having an official education on proper biomechanics/handling. Additionally, this section included questions related to the participants’ daily life work tasks. An intensive literature review and a series of discussions among the research team members and experienced clinicians were utilized to improve the face validity of this section.

The third section included the following standardized outcome measures:

Nordic Musculoskeletal Questionnaire (NMQ): this questionnaire has been extensively used in WMSDs research studies in the general population and among different occupational groups. This scale measures 12-month and 7-day prevalence of musculoskeletal pain complaints in addition to functional limitations due to these complaints. A sample question from NMQ is: “Have you at any time during the last 12 months had trouble (ache, pain, discomfort) in . . . ”. NMQ is valid and reliable to investigate WMSDs in upper quadrant [51–53].

Depression Anxiety Stress Scale (DASS21): this is a self-report survey used to assess the severity of mental health symptoms over the previous week including depression, anxiety, and stress. A four-point Likert scale is used, ranging from (0) “did not apply me at all” to (4) “applied to me very much or most of the time”. The higher DASS scores indicate more severe mental health symptoms [54]. DASS21 has a strong validity and reliability [53, 55].

Pittsburgh Sleep Quality Index (PSQI): is a valid and reliable instrument used to measure the quality and pattern of sleep [56]. The PSQI is a 19-item self-reported questionnaire for assessing sleep quality over the previous month. A sample question from the test is: “How long (in minutes) has it taken you to fall asleep each night?”. The PSQI global score ranges from 0 to 21. A higher PSQI score indicates a worse sleep quality [56]. A PSQI total score ≥5 or reflects a poor sleep quality [57].

International Physical Activity Questionnaire –short form (IPAQ-SF): this is a measure for physical activity level categorizing it into high, moderate, and low. The three test scores categories are: low or trace physical activity (below 600 MET. min/week), moderate physical activity (600 –1500 MET. min/week), and high physical activity (at least 3000 MET. min/week). A sample question from the test is: “During the last 7 days, on how many days did you do vigorous physical activities like heavy lifting, digging, aerobics, or fast bicycling?”. IPAQ showed good reliability and validity [58–60].

The entire questionnaire for this study was validated by an expert panel discussion and piloted on 15 nurses. Participants of the pilot study reported that the questionnaire was clear and easy to follow and it needed about 15 minutes to complete. Our pilot study DASS21 score showed high internal consistency for scores as supported by Cronbach alpha coefficients, which were 0.91 for the depression domain, 0.88 for the anxiety domain, and 0.94 for stress domain.

2.4 Statistical analysis

All statistical analyses were conducted using SPSS 23.0 (SPSS, Inc., Chicago, IL, USA). Means and standard deviations were used to describe continuous variables and frequencies and percentages were used to describe categorical variables. Bivariate correlations between upper quadrant NMQ 12-month pain and each collected outcome measure data were conducted. When a correlation p-value was <  0.15 for a factor, this factor was used in the corresponding regression model as a potential predictor. Multivariable logistic regression analyses were conducted for each NMQ upper quadrant region using a backward conditional method to identify significant predictors for each region 12-month WMSDs. A p-value <  0.05 was considered to be significant for predictors in the final regression model.

3.1 Participants’ characteristics

In total, 597 nurses completed and returned their surveys successfully with a 79.6%retention rate. About 52.8%of the participants were females. Nurses’ age ranged between 22 and 57 years with a mean age of 32.1 (±5.71). Nurses’ experience ranged between 1 and 35 years, with a mean of 9.28 (±5.41). Geographical distribution across Jordan of the sample was as follows: 49.1%North, 38.9%Middle, and 12.1%South. About 41.2%of the respondents worked in governmental hospitals, 44.7%in military hospitals, and 14.1%in private hospitals. Nearly half of the respondents (50.9%) worked full-time (30–40 hours/week). Overall, respondents worked 43.4 (±4.71) hours/week on average. About 440 of respondents (73.7%) worked 3 to 5-day shifts, while 21.8%worked 1 to 2-night shifts per week. About 19.3%of nurses were working in operation rooms, 24.1%in surgical wards, 21.6%in ICU, 20.4%in internal wards and 14.6%in pediatric wards. Among our participants, 162 (27.1%) nurses reported that they were cigarette smokers and 135 (22.6%) nurses were waterpipe smokers.

Regarding nurses’ physical activity level as measured by IPAQ, 40.2%of nurses participated in high level, 31.4%participated in moderate level, and 28.5%participated in a low-level physical activity. Regarding sleep quality, global PSQI mean score for respondents were 7.75 (±3.72) with 68.2%having poor sleep quality as indicated by PSQI scores ≥5. Table 1 shows the participants’ characteristics.

Our results showed that the prevalence of WMSDs at any body site was 91%in twelve months. 12-month pain prevalence was found as 61.1%at neck, 47.2%at upper back, 46.7%at shoulder, 27.3%at wrist and hand and the lowest prevalence was reported at elbow with 13.9%. Table 2 below shows the 12-month and seven day prevalence of WMSDs as well as a functional limitation due to these disorders as measured by NMQ.

Being female was a significant predictor of more shoulder (β= 1.3, P = 0.001) and elbow (β= 0.68, P = 0.014) WMSDs. Cigarette smoking was a significant predictor of reduced neck (β= –0.4, P = 0.048) and wrist (β= –0.54, P = 0.034) WMSDs. In addition, working in governmental hospitals was a significant predictor of less neck WMSDs as compared with private hospitals (β= –0.69, P = 0.018). Increased WMSDs of the neck was significantly associated with day shift working (β= 0.15, P = 0.013), while number of night shifts was significantly associated with less shoulder WMSDs (β= –0.19, P = 0.013). Additionally, sick leave was significantly associated with increased neck, elbow and wrist WMSDs (β= 0.45, P = 0.042), (β= 0.69, P = 0.01) and (β= 0.64, P = 0.008) respectively. WMSDs in the neck was significantly associated with increased nurses’ depression (β= 0.05, P = 0.041), while anxiety was found to be significantly associated with increased shoulder (β= 0.10, P = 0.003), and wrist (β= 0.08, P = 0.003) WMSDs. On the other hand, stress was a significant predictor of less shoulder WMSDs (β= –0.07, P = 0.035).

Environmental obstacles and high work demands significantly predicted more shoulder (β= 0.42, P = 0.041), wrist (β= 0.48, P = 0.035), and upper back (β= 0.49, P = 0.011) WMSDs. Lack of patients’ handling equipment significantly predicted more shoulder WMSDs (β= 0.60, P = 0.028). Pushing or pulling activities during work more than three times was a significant predictor of increased shoulder (β= 1.17, P = 0.002) and wrist (β= 1.04, P = 0.012) WMSDs. Increased shoulder, elbow, wrist and upper back WMSDs were significantly predicted by poor sleep quality (P <  0.05). Finally, being engaged in a high physical activity level was a significant predictor of more neck and shoulder WMSDs (P <  0.05). Table 3 shows all significant predictors of upper quadrant pain during the last twelve months.

4.1 Prevalence of upper quadrant 12-month WMSDs

The prevalence of 12-month WMSDs at any body site in this study was 91%. This high level of WMSDs represent a serious health challenge and might reduce nurses’ productivity during patients’ care. This prevalence is considered within the highest prevalence rates reported in previous studies worldwide (48%–95%) [5, 61–67]. To our knowledge, there are no published data related to WMSDs among nurses in Jordan other than our study. Smith et al. reported the highest prevalence of WMSDs among nurses in a Korea. This study utilized the standardized NMQ and reported a prevalence rate of pain at any body region of 94%. The researchers suggested that this prevalence rate was related to mechanical load, body composition, work organization, or a mix of all previous factors [37]. On the other hand, the lowest prevalence of WMSDs among nurses (48%) was reported in Sweden [61]. A Turkish study, conducted on 120 nurses from four hospitals using the NMQ, reported that WMSDS prevalence was 41%neck pain, 34%shoulder pain, and 26%hand and wrist pain [63]. Utilizing the NMQ measurement, nurses in New Zealand demonstrated a high prevalence of back and neck pain (35%and 31%respectively) compared to other types of jobs such as postal workers (31%, 26%) and office workers (24%, 22%) [15]. In a recent systematic review of 22 articles with 9347 participants, the prevalence of low back pain and neck pain during life and during last 12 months among Iranian nurses were 63%and 61.2%respectively [14]. Based on cross-sectional studies conducted in Boston –United States and Nigeria, the annual prevalence of work-related WMSDs was up to 50%among nurses, which is considered as a major cause for decreasing work efficiency [5, 68].

Only 23.3%of our participants reported that they asked for sick leave due to WMSDs. It is probable that nurses might adapt to pain due to the nature of their work and only look for medical care or rest when the symptoms became unbearable. Other researchers reported that ignoring symptoms of WMSDs along with self-management might decrease the rate of sick leave [5]. Tinubu et al. reported that 30%of participants in their study adapted with their body symptoms [5].

In previous studies, neck pain was identified as the site with the second highest prevalence of WMSDs (after low back pain) with prevalence between 15%and 55%in 12 months [5, 70]. In this current upper quadrant study (which did not consider low back pain), the neck was the highest site of 12-month WMSDs among Jordanian nurses with a prevalence of 61.1%. Similar to previous studies, this study 12-month WMSDs prevalence at shoulder was 46.7%. Shoulder and neck symptoms of pain measured by the NMQ were 75%and 63%respectively in Korea [37]. These findings reflect that WMSDs in the nursing profession in Jordan is relatively similar to other countries worldwide. However, the prevalence in Jordan is considered among the highest worldwide. This higher prevalence (as compared worldwide) might indicate worse work environment and job tasks, poor ergonomics including lack of handling equipment, lack of training on safe handling techniques, high working load, and lack of knowledge about proper body mechanics.

4.2 Predictors of upper quadrant 12-month WMSDs

Our study investigated large number of factors as possible predictors of WMSDs among Jordanian nurses. Different systematic reviews reported that physiological, psychological, and individual characteristic factors were significantly associated with a higher prevalence of WMSDs among nurses [13, 18–21]. However, no single previous study was as comprehensive as this study in terms of number and variety of investigated predictors with strong measurement psychometrics. Studying many possible predictors in one large sample study is informative and innovative.

The findings of this present study showed that stressful activities such as pulling or pushing were significantly predicting increased levels of shoulder and wrist musculoskeletal pain, particularly when these stressful tasks were practiced more than three times a day. Researchers found strong evidence suggesting that physical factors were significantly associated with increased nurses’ WMSDs, predominantly when combining more than one factor [13, 33]. Awkward back posture, strenuous shoulder movements, pushing and pulling were the strongest documented WMSDs among nurses [34–36]. Our findings demonstrate an obvious agreement with previous studies in this regard as nurses’ job tasks or work activities are not fundamentally different across different countries.

Many studies reported that females had a higher WMSDs prevalence than males, which is consistent with our findings [67, 72]. The current study showed a significant association between gender and WMSDs in the shoulder and elbow. Sikiru and Shmaila concluded in their study that the variation of physiological and anatomical structures between male and female might play a significant role in developing WMSDs. [73] On the other hand, researchers speculated that females might tend to seek medical care and report WMSDs more than males [74]. Therefore, it seems that females tend to report more pain than males and probably need more consideration related to their musculoskeletal pain complaints.

This current study showed that cigarette smoking and waterpipe smoking was negatively associated with WMSDs. Naude et al. reported that the rate of WMSDs in smokers was not different from their non-smoker peers and that smoking was not a significant predictor of WMSDs. However, their study had a low number of smokers [75]. Different studies reported that smoking was positively predicting increased WMSDs, particularly when co-occurred with other factors such as high BMI, poor lifestyle, and stressful work experience [76–78]. In Jordan, smokers might tend to get more breaks during work to smoke. Consequently, one possible explanation for our findings related to smoking might be that smokers are more likely adherent to work breaks. Breaks during work are linked with lower levels of musculoskeletal pain among workers which might explain the negative association found between smoking and WMSDs in our study [79].

Interestingly, our results showed that higher levels of neck and shoulder WMSDs were significantly predicted by higher levels of physical activity but not with moderate physical activity levels. Studies showed that nurses with lower physical activity levels reported higher levels of WMSDs compared to nurses of more physically active levels [78]. Turker et al. reported more than 50%(N = 3,132) of Canadian registered nurses were overweight and did not meet physical activity recommendations [80]. The same finding was reported in a recent study conducted by Abdulla et al., (2018) who reported that 45%of nurses who suffered from WMSDs were not participating in regular physical activity [81]. There is controversial point of view in the literature regarding physical activity relationship with upper quadrant WMSDs. According to a recent systematic review, some studies found negative associations between physical activity and upper quadrant WMSDs and a few others found the opposite [82]. Possibly, nurses could have increased the stress on their body by combining high job workload with high level of physical activity.

In this study, working hours per week, day shifts, lack of handling equipment, compliance to apply proper posture during working, and work demands were significant predictors of upper quadrant WMSDs. Carrivick et al. found a significant association between moving or lifting load and neck WMSDs as well as bent or twisted back on developing back WMSDs [83]. Wang et al. reported that manual handling might explain increased levels of WMSDs among nurses as a possible risk factor [84]. Lifting objects over 35 pounds (16 Kgs) might increase the risk of WMSDs injuries for healthcare providers [85]. Therefore, the American Nurses Association recommended eliminating manual patient handling [11]. Different levels of research suggested that multicomponent strategies like ergonomics, patient handling training programs, lifting machines, and no lifting policies are effective in reducing WMSDs among nurses [86–90]. In general, factors associated with increased levels of WMSDs might include inappropriate work environment as well as overloaded body segments while performing movements with extreme forces and repetition and/or improper posture [91, 92]. Many other risk factors were reported among nurses subjected to increased levels of musculoskeletal pain complaints [13, 18]. These pain complaints were linked to job tasks, including patient handling on daily work routine [5]. These physical factors are associated with psychosocial factors like job stress, monotonous tasks, high perceived workload, and time pressure were found significantly associated with the development of WMSDs among nurses [93].

This study is unique worldwide as it identified the associations between nurses’ WMSDs with sleep quality and mental health symptoms. Our study showed a high prevalent of poor sleep quality. In addition, the results showed that increased PSQI scores significantly predicted increased neck, shoulder, elbow, and wrist WMSDs. Very limited number of studies linked sleep quality with musculoskeletal pain [94, 95]. Previous studies suggested that environmental factors and pathological conditions are statistically related to sleep disruption [96]. Various factors were identified related to sleep deficits such as demographics, health status, and jobs demands [48]. Several studies showed that sleeping disorders among nurses do not affect health status only, but also these disorders might influence nurses’ work outcomes quality [97]. Finally, it was not surprising to find a link between mental health symptoms (such as depression, stress, and anxiety) and WMSDs as this issue was repetitively documented in the literature among different occupational groups [53, 98–100].

4.3 Clinical implications

WMSDs risk assessment should be conducted for nurses at their workplaces. Modifiable risk factors identified in this study (including sleep, physical activity level, ergonomics, workload, diet, and mental stress) should be fully considered in both of prevention and treatment. Management of nurses’ WMSDs might include optimizing work environment-related factors such as job satisfaction and workload as well as life balance [101, 102]. Rehabilitative preventive and treatment interventions are also available through occupational and physical therapy services. These rehabilitative interventions include exercises for joints flexibility and muscular strength, enhancing appropriate biomechanics, ergonomics, working positions, breaks, and optimal tools designs. [103–106]. Female nurses should take more precautions to avoid potential WMSDs.

The majority of collected data were self-reported. Our participants might have reported their WMSDs with some subjectivity as pain perception might vary across individuals. However, the questionnaires were filled out anonymously, and participants had clear instructions and directions to report what they had actually felt without any negative or positive consequences associated with their answers. Additionally, although we attempted to represent all Jordanian hospitals in all geographical regions, the recruited sample might be biased toward including more eager and cooperative nurses. This study could have been improved if it used a longitudinal design to reveal the progressive nature of WMSDs. Furthermore, a better representation of Jordanian geographical regions could have improved the study. Future studies are needed to evaluate the efficacy of various interventional techniques in reducing the level of WMSDs among hospital nurses in Jordan.