Musculoskeletal symptoms in nursing students: concept analysis.

OBJECTIVE
to analyze the musculoskeletal symptomatology concept in undergraduate nursing students through Rodgers' evolutionary method.


METHOD
An integrative review of the literature was performed for the identification and selection of ten articles. A concept analysis was performed according to Rodgers' evolutionary method. Article search was performed using the EBOSCO Host platform, Virtual Health Library and Google scholar for the years from 2004 to 2018.


RESULTS
Based on the 3 elements of Rodgers model we found: 1) substitute terms and related concepts, where musculoskeletal disorders and musculoskeletal symptoms were highlighted; 2) as essential attributes of the concept we highlight pain and discomfort, as well as, measurement using the Nordic Musculoskeletal Questionnaire; and 3) risk factors were identified as antecedents, and the consequences were the impact on students' lives.


CONCLUSIONS
This study contributes to the knowledge and clarification of the concept of musculoskeletal symptomatology in nursing students.


INTRODUCTION
The musculoskeletal symptomatology is one of the most common conditions in our society, affecting the individual regardless of gender, age or socioeconomic context. The presence of musculoskeletal symptomatology is considered as one of the main factors of disability during an person's life cycle (1)(2) .Therefore, it is currently considered a real public health problem due to the impact it has on an individual's personal and professional life, as well as, on productivity, or even by the rate of absenteeism and decrease in quality of life, which is increasingly linked to this type of symptomatology (1,3) .
Considering a nurses' working conditions and performed tasks, nursing is one of the professions in which the impact of musculoskeletal symptomatology is more evident (4) . These conditions range from biomechanical, physiological, psychological and social requests, regardless of the position and function of the nurse, also depending on the organization, not allowing recovery and adequate rest times (4) .
Also, nursing students, once they begin their academic training, perform and experience the same working condition situations as the nurse, being exposed to the same factors that can trigger this musculoskeletal symptomatology (5) .
To understand this scenario, the consulted literature shows that this concept has variations in its definition, which evidences the need for refinement and clarification of the concept of musculoskeletal symptomatology. It is possible to identify various forms / words / expressions that represent the concept and, in a certain way, may be considered as synonyms. Nevertheless, they also convey a lack of consensus in their use in the literature consulted. For this reason, it is necessary to clarify the concept of musculoskeletal symptoms in nursing students, identifying their attributes, antecedents, consequences and, also, the protective factors that may contribute to their minimization or prevention. The need for concept analysis began with the philosopher Aristotle. By then, a concept was abstractions of reality consisting of essential characteristics (6)(7)(8) .
Thus, it is justified the study of the conceptual analysis of the term musculoskeletal symptomatology in undergraduate students in nursing, under the evolutionary view of Rodgers (6) .

OBJECTIVE
To analyze the musculoskeletal symptomatology concept in undergraduate nursing students through Rodgers' evolutionary method.

Ethical aspects
It should be emphasized that this study does not require analysis by the Ethics Committee because it is an integrative review and concept analysis.

Design, study location and period
For this study two methodologies were associated: Rodgers' evolutionary method and integrative literature review (9)(10) . Rodgers' evolutionary method (6) , which is also known as the evolutionary method of conceptual analysis in the literature, is characterized by being an inductive and descriptive model, which is used to investigate the history of a particular concept (6) . This model understands that a concept is used according to its particular context, is dynamic and changes over time (7) . This model is based on a philosophical current, referring that the analysis of a concept is fundamental for knowledge, as it allows the identification its characteristics and common phenomena (6) .
The lack of clarity of the concept can contribute to a commonsense interpretation, depending upon who will use it. In order to have a perfect understanding and be used for scientific knowledge, the concept must be shaped through conceptual analysis (11) permitting language uniformity and facilitating its comprehension (8,11) . This is a rich methodology because it uses mixed studies stages (qualitative and quantitative), which subsidizes fundamental aspects for the analysis of the concept under study (11)(12) .
In this method three essential aspects for the development of the concept are distinguished: meaning, use and application. In other words, the meaning of a concept depends on the context in which it is used (8) . It consists of six interactive and simultaneous steps, that help us to understand the concept and its context (6) , as presented in Chart 1. 5. Identification of an example of the concept to be investigated 6. Determination of the implications and hypotheses for the concept Source: Adapted from Rodgers (6) .

Stages of Rodgers' Evolutionary Model
The methodology selected for identification and selection of the bibliography was integrative review of the literature. This was the option was because it included an association between primary and secondary research, allowing the synthesis of results and a more comprehensive and deepened understanding of the concept (9)(10) . It also permits the generation of new knowledge regarding the concept being studied. This review is in line with the fourth stage of the evolutionary method, as it will be from this point that the characteristics of the concept will be identified. The methodological rigor applied to this method was taken into account, following the 6 different phases as recommended: 1) Identification of the subject and selection of the hypothesis or question of research for the elaboration of the integrative review; 2) Establishment of criteria for inclusion and exclusion of studies / sampling or literature search; 3) Definition of the information to be extracted from the selected studies / categorization of the studies; 4) Evaluation of studies included in the integrative review; 5) Interpretation of results; and, 6) Review presentation/ knowledge synthesis (9)(10) .
The inclusion criteria used for the selection of articles were: publications in Portuguese, English and Spanish; articles with full text available and published between January 2004 and June 2018.

Study protocol
The research question was formulated according to the PCC acronym (13) as following: P (Population -nursing students); C (Concept -musculoskeletal symptomatology); C (Contextduring the undergraduate Nursing Degree). We therefore established the following research question: What is the concept of musculoskeletal symptomatology applied to undergraduate nursing students?
The electronic search was carried out in the following health databases: Bibliotheca Virtual em Saúde (BVS); SCOPUS and EBSCOhost and Google Academic. The following descriptors were used: (musculoskeletal symptoms) OR (musculoskeletal disorders) OR (Musculoskeletal system) AND (Nursing Students).
To analyze and synthesize the articles selected, were used fundamental elements of Rodgers' evolutionary method (6) .

Samples, inclusion and exclusion criteria
The articles followed the order: reading the title, abstract and full text. 544 references were identified, and 470 were rejected by title. From the 74 remaining articles, duplicates and without full text were excluded. 10 articles were selected for final revision.

Analysis of results
The data analysis was carried out based on exploratory, selective, analytic and interpretative reading of articles that composed the final sample of the integrative review and concept analysis (6) . The results were presented by charts and discussed in the appropriate literature.
In the primary studies, the samples varied between 59 (19) and 1.163 (15) students. Nine descriptive studies (1,14,16,18,21) were included with the level of evidence III and a narrative review of the literature, with level of evidence IV (17) .
Based on the researched literature and articles selected, and considering the research concept, musculoskeletal symptoms are a problem described and addressed in all articles. It highlights the use of the concept in health, namely in Nursing, Ergonomics and Occupational Health.
Musculoskeletal symptomatology is mentioned as a current problem in nurses (15) and is highlighted as a risk to nursing students' health (14,20) , due to the activities carried out either in the school environment (5,15) or during clinical teaching (5,15) .
Having in mind the fundamental elements of Rodgers' evolutionary method (6) , this analysis allowed us to identify the characteristics of the concept, essential attributes and contextual basis of the concept, as shown in Chart 3.
This concept analysis allowed us to identify the essential attributes that characterize the musculoskeletal symptomatology, namely: pain; discomfort and numbness; limitation of normal activities such as work, domestic service or hobbies; and, that the most affected areas are the lumbar region, followed by the neck, shoulders, wrists and knees (14,21) .We chose the concept of musculoskeletal symptomatology because it is characterized as a subjective experience of alteration of function or appearance of the body (21) , not being considered a medical diagnosis.
Nursing always keeps its essential focus on the use of the 4 elements that constitute the nursing metaparadigm: person, health, environment and nursing for the expansion of knowledge. The use of the musculoskeletal symptomatology concept fits the person living this subjective experience. In this sense, it is not possible to develop care models without having a referential from personal and collective reflections on the value of this care in the socio-political context in which it operates. Furthermore, nowadays professions linked to social sciences (where Nursing is inserted), enhance the health of the citizen and the construction of citizenship itself (22) .
The use of this concept allows a unified language that expresses those elements of care, and comparisons between clinical contexts, client populations, geographical areas or time (23)(24) . This line of thought is a guide to understand the concept and contributes to its adaptation to this population (25) .
Musculoskeletal symptoms are described as an unpleasant physical perception, pain, feeling of weight, tingling and fatigue of an individual, according to the individual's perception (20,23,26) .
The Nordic musculoskeletal questionnaire was the most used to evaluate the presence of musculoskeletal symptoms. It allows to measure the attributes that characterize the concept under analysis, that is, to identify the most affected areas with pain, numbness and disability for 12 months, which makes it one of the most used instruments to characterize this symptomatology (5,19,21) .
This instrument was translated and validated for the Portuguese population, showing a good internal consistency according to the coefficient of reliability Kuder-Richardson of 0.855 (25) . The Kappa coefficient ranged from 0.8 to 1, showing good levels of reproducibility in the test-retest. It is an easy to apply self-administered questionnaire, as it presents a body diagram to identify the anatomical regions. It was applied in Portuguese nursing students to evaluate musculoskeletal pain and its risk factors (21) .
In these articles, the causes most described as being at the origin of this type of symptomatology are: overload; repetitive movements; inappropriate postures related with positioning and transferring patients; and the excessive use of the computer (5,(14)(15)27) . Being a female, nursing student and attending the last year of the nursing degree, are considered as the antecedents which are at the origin of the musculoskeletal symptomatology (5) .
A Portuguese study also refers as probable cause of this symptomatology: a previous accident and a family history of musculoskeletal disorders (21) .
These consequences are associated with the establishment of social and affective bonds, the requirement of long hours of study, the demand for greater autonomy and responsibility during the nursing degree (which is considered complex and challenging, as they constantly must deal with human limits) (22) . By having a very practical component, the nursing degree permits students to perceive their limitations in terms of knowledge, generating feelings and sensations that can alter their health balance (1,22) .
All these findings are in line with what is described in the literature on musculoskeletal symptomatology in nurses. Nursing students are exposed to the same kind of work as nurses when they are in clinical teaching context, in practical classes and in extracurricular practices, adopting inappropriate postures, repetitive movements and weight overload (3) . Therefore, students end up presenting the same changes as the nurses who are already in clinical practice: anxiety, stress, changes in quality of life, decreased physical and mental performance (22) .
The consulted articles emphasize the need to implement effective interventions and strategies to prevent and reduce symptoms Chart 3 -Musculoskeletal symptoms according to Rodgers's evolutionary method (6) Concept characteristics (related and substitutive) Essential attributes of the concept (express their nature)

Study limitations
This concept analysis used the integrative review methodology to identify, select and include the articles.
However, there are still some limitations, namely the number of databases consulted, access to the full text and the language (only studies in Portuguese, Spanish, and English were included).
Despite the positive implications that emerged from this work, the use of the evolutionary Rodgers (6) method may be one of the limiting issues. As such, it is suggested the use of exploratory methodologies, as the analysis of the concept of musculoskeletal symptomatology in nurses. This will probably bring out other attributes and characteristics that may be associated with the concept.

Contributions to the sector of nursing, health, or public policies
Both the concept analysis under the evolutionary perspective of Rodgers and the integrative revision in this article, add value to qualitative studies. It requires scientific precision that reduces us to the essence of the concept, one of the characteristics that define qualitative methodology.
This concept analysis permitted the clarification of the concept of musculoskeletal symptomatology and the identification of its attributes. Furthermore, it allowed the identification of the musculoskeletal Nordic questionnaire as an instrument that measures the attributes of musculoskeletal symptomatology in nursing students. On the other hand, it enabled the identification of the predisposing factors for musculoskeletal symptoms and its consequences in nursing student's life.
The development of intervention programs seems to be fundamental for the prevention of musculoskeletal symptoms.
Nursing degree admission requires students to have cognitive, physical and emotional resources. The university / school must provide conditions so that nursing students can deal with situations that may interfere and compromise their quality of life.

CONCLUSIONS
The objective of this study was to contribute to the knowledge and clarification of the concept of musculoskeletal symptomatology in nursing students, describe their attributes, risk factors and health consequences. It is undeniable the importance of knowing the factors that contribute to musculoskeletal symptomatology in order to permit an earlier intervention.
Therefore, preventive interventions should be implemented to reduce the occurrence of musculoskeletal symptoms. Factors that predispose to this symptomatology must be considered, such as: overload; repetitive movements; inappropriate postures related with positioning and transferring patients; and the excessive use of the computer. Attention should also be paid to the differences in gender, family history, personal history of accidents, physical exercise, among others.
An assessment, before and after the intervention, should be made on: the quality of life, subjective well-being and psychological health (stress, anxiety and depression), to verify if there were improvements in the variables that have been studied as consequences of this symptomatology.
The use of both methodologies together allows the answering of the outlined objective, with responsibility and scientific rigor, showing once again how qualitative methodology can contribute to the production of useful information able to be transferred to practice.
For future research it is recommended to intervene in the prevention of musculoskeletal symptoms, considering the risk factors, as well as, assess the impact of this intervention by measuring the quality of life, well-being and psychological health (stress, depression, anxiety) of undergraduate nursing students.