Non-specific low back pain and its relation to the nursing work process

Objective to relate nonspecific low back pain within the nursing work context with their workloads, attrition processes and the risks of illness. Method a cross-sectional study with 301 workers from a general hospital in the south of the country. The Nordic Musculoskeletal Questionnaire and the Work Context Assessment Scale composed of three dimensions were used: working conditions, work organization and socio-professional relations. The association of variables with low back pain was tested using bivariate and multivariate analyzes. The measure of association used was the Odds Ratio and its respective intervals with 95% confidence. The data collected were discussed under the theoretical framework of the work process within the marxist conception and the theory of social determination of the health-disease process. Results there was a statistically significant association between the dimensions of work organization and working conditions with low back pain and they obtained a critical classification meaning moderate risks to the professional illness. Conclusion the study allowed a better understanding of the nursing work process and its relation with nonspecific low back pain and signaled that changes in the organization and working conditions should occur in order to reduce the risks of nursing workers’ illness.

The NMQ identifies musculoskeletal pain or discomfort in the last twelve months as well as in the last seven days in the anatomical areas shown by a figure.
Regarding the overall mean of all EACT dimensions, the value was 3.2, classified as critical, with unsatisfactory working conditions and moderate risks for illness. The averages of each dimension and risk classification are shown in Table 2.
In the work organization dimension, the items "the tasks are repetitive" and the "work rhythm is excessive" and in the "working conditions" dimension the item "existing furniture in the workplace is inadequate" obtained a severe classification, which indicates risk of becoming ill and requires immediate action. The only items considered satisfactory belong to the dimension "socio-professional relations" and were "there are difficulties in the communication between manager and subordinates", "the information that I need to perform my tasks are difficult to access" and "lack of support of the bosses for my professional development ". The "working conditions" dimension (p = 0.007) and "work organization" (p = 0.004) showed a statistically significant association with low back pain (Table 3). In the "organization of work", the situation considered as severe increased by 9.06 the chances of presenting low back pain; in "working conditions," the situation also classified as severe increased by 3.46 times the chance of having low back pain.

Discussion
It was attempted to associate low back pain with the work process in a hospital unit with a sample of 301 nursing workers. The approach was innovative because the combination of these instruments to contextualize occupational low back pain was not found in the literature. It is important to emphasize the importance of research based on the experience of workers, considering that these generate knowledge, information and investigate the social organization in the workplace and help in the planning and execution of actions aimed at the prevention of health problems (3,18) .
The high prevalence of reports of pain symptoms and musculoskeletal discomfort in the lumbar region in this study demonstrates the impact of this problem on the nursing team and expresses a negative influence on the health of these workers. It is, therefore, an important concern in nursing practice and the risk factors of lumbar algias should be identified and resolved with priority (19) .
Labor burdens such as overload, fatigue and moodiness (physiological and psychic workloads) were related to pain. High physical or mechanical demands stress and fatigue the muscles and can initiate a process of low back pain by prolonged positions and repetitive movements. The relationship between fatigue and pain seems to encompass metabolic and structural lesions that influence pain physiology-related channels such as the basal glands, thalamus, limbic system, and cortical center (26) . Psychosocial factors such as bad mood at the end of the journey and fatigue can influence chronicity, frequency, perception and pain threshold (27) .
Fatigue seems to play an important role in the etiology of psychophysical overloads. It can be conceptualized as a development of a feeling of physical and mental tiredness that modifies alertness and alertness, affects the ability to work and perform tasks. It can progress to chronic fatigue, increasing susceptibility to occupational diseases.
In this sense, the poor working conditions increase the risks (28) . The study that evaluated the prevalence of musculoskeletal discomfort, work capacity and fatigue in nursing professionals, in addition to the high prevalence of musculoskeletal discomfort, showed greater fatigue and the need for rest, conditions that directly influenced the ability to work (28) . Another study found a statistically significant association between musculoskeletal disorders and chronic occupational fatigue among nurses and the need for preventive measures (29) .
In the hospital unit studied, the large portion of the servers is a nursing professional. Its service is organized with centralization of decisions and division of tasks between nurses and nursing technical personnel.
Some tasks are individualized, others are performed with the help of another worker. They involve repetition of activities and movements and generate the same wear for a while. They are subject to prolongation of the journey by the relay in shifts, double bond or overtime and exposed to a wide variety of workloads. The multicausality of low back pain is justified. In this sense, the work process may be a cause for injuries such as low back pain and other musculoskeletal disorders (MSD) related to contact with patients, exercise of procedures and type of task developed (30) .
The dimensions of EACT "work organization" and "working conditions" had a statistically significant association with lower back pain and a critical classification with a moderate potential for workers' illness, which demands the taking of measures in the medium and short term. Similar results were found in a study with primary care workers (18) . Another study that analyzed the risks of illness of the nursing professional related to the work context in a psychiatric hospital also found a critical classification in the "work organization" dimension, but serious in the "working conditions" (17) . When precarious and subject to various workloads, authors describe working conditions and their organization as strong factors of illness (4,9,14,30) and nursing is exposed to precarious conditions in a chronic way (30-31) . One study found that work activities favor lumbar MSD and shows the importance of an occupational control with organizational, technical and individual measures (32) .
In the dimension "work organization", the items "excessive work rate" and "tasks are repetitive", which are physiological and psychic workloads, presented The lack of materials and equipment, maintenance of furniture and inadequate infrastructure enhance the physical burden (14) .
The "socio-professional relations" dimension, despite a critical risk assessment, did not present a statistically significant association with low back pain. The global process studied involves many causes and determinants that influence the work-health relationship. We sought to establish the biopsychic nexus that is the concrete expression of human corporality within the historical process at a given moment. In some of these moments, it can be identified as disease, defining a pathological profile. To establish it in a collective, it is necessary to analyze the work process and its conditions until its expression in the body of the workers (6) . The internal materiality was expressed by the occurrence of nonspecific low back pain that was manifested by the interaction between the loads.
The wear and tear that can lead to aggravations, even though they acquire individual corporeality, must be considered alongside reproductive processes in capitalist societies and can be measured by signs and symptoms that are not specific to the pathological profile and other indicators (3,6) . The interrelationship of organizational factors and working conditions in this study are not isolated risks, but they act dynamically with each other, they add up and become more potent because they were generated under certain conditions (4,14) . There are many workloads in this scenario, emphasizing the physiological, psychic and mechanical that have been related to low back pain. if workers are aware of the risks, they must maintain constant and permanent struggles for better structured working conditions as a collective practice (30) .
Wear involves the loss of the capacity to develop initiatives and take control, it is the systematic denial of the creativity of the collective worker. Therefore, the process of attrition can interrupt the struggle of opposition to the loss of biopsychic capacities and the development of their potentialities. On the other hand, proper management of their activities will make them less fragile, with the form of workers gaining control over their own lives (3) . Care should be taken in the exposure to various workloads that can lead to illness to identify them early and to develop prevention strategies, since it is also possible to reverse losses and capacities (6,9) .
As a limitation of this study, it is verified that the studied variables involve subjectivity and selfreports. Your results should be analyzed with caution.