Musculoskeletal discomfort , work ability and fatigue in nursing professionals working in a hospital environment

Objective: To evaluate the musculoskeletal discomfort, work ability and residual fatigue in nursing professionals working in the hospital setting. Method: Cross-sectional study with professionals from a medium-sized public hospital. The Nordic symptom questionnaire, the work ability index, and the need for recovery scale (fatigue) were used. Data were analyzed descriptively and inferential tests were applied in order to verify the association of fatigue and work ability, and compare the fatigue among sectors analyzed. Results: Participation of 110 professionals in the study. A total of 86.24% of workers reported musculoskeletal discomfort, with a higher prevalence in the cervical, thoracic and lumbar spine. Approximately 43% of professionals presented residual fatigue. There was a significant association between fatigue and reduction of work ability (p<0.003), as well as association between younger age and greater fatigue (p<0.03). Conclusion: Results demonstrated a high prevalence of musculoskeletal discomfort in the previous year and a considerable number of professionals with residual fatigue. There was a substantial portion of workers with moderate work ability and requiring attention in the medium term.


INTRODUCTION
Infectious-contagious diseases and work-related musculoskeletal disorders (WMSD) are among the most frequent occupational diseases in nursing professionals.There is also physical, psychic and organizational burden that may be associated with standing work, weight lifting, inadequate postures and psychophysical aspects (1) .WMSDs can cause dysfunction and disability and impose high costs with payed sick leave.They are recognized as one of the major responsible for high absenteeism and reduction of productivity.Workers with WMSDs are affected by intense psychic suffering, stress and dissatisfaction, which interfere directly in their work ability and quality of life (2) .
Work ability can be understood as professionals' physical and mental capacity to face physical and mental demands arising from their activity, both in the present time and the future (3) .Worker's health and occupational demands must be balanced for the preservation of this ability, which becomes possible by offering good conditions (4) .If this aspect is not contemplated, there may be an exposure to stressors and consequently, a state of fatigue.
Work-induced fatigue has an important role in the etiology of psychophysical overloads (5) .Recently, studies have adopted measures of fatigue in the nursing context (3,(6)(7) .This variable has demonstrated a high prevalence and an association with deleterious working conditions (6,(8)(9) .Fatigue is a process of physical and psychological exhaustion that changes the states of alertness and surveillance, affects skills and compromises the development of occupational activities (10) .Initially, fatigue is a result of physiological processes.In cases of prolonged exposure, it may evolve to a state of chronic fatigue and, later, to pathological fatigue (4) .Thus, residual fatigue can be defined as an accumulation of psychophysical symptoms resultant from constant exposure to stressors without periods of rest and due recovery (11) .It is characterized by the presence of insomnia, difficulty in rest, irritability, discouragement and difficulty to perform activities both in the occupational and home environments (3)(4) .The greater the workers' exposure to these factors, the greater their susceptibility to occupational diseases, a situation experienced by nursing professionals given their frequent exposure to poor working conditions.
Occupational risk factors associated to nursing professionals' activity may be related specifically to the complexity of care, double shifts, physical and mental work overloads and overtime (12) .Multidimensional measures such as fatigue are key in the context of nursing activity, because they can help to detect situations inducing cumulative loads and avoid long-term effects (7) .In addition, the traditionally used analysis of work ability and musculoskeletal discomfort is a useful tool to evaluate health status and plan preventive actions.Based on the above, emerges the issue of the association between work-induced fatigue, work ability and musculoskeletal discomfort with the view of a broader understanding of risk factors arising from the activity of nursing professionals working in hospital settings.Thus, the aim of the present study is to assess the musculoskeletal discomfort, work ability and residual fatigue in nursing professionals working in a hospital environment.The specific objectives of this study are to estimate the risk of exposure to residual fatigue and the presence of musculoskeletal discomfort and to compare the level of fatigue among different sectors of a medium-sized hospital.

Type of sTudy
This is a cross-sectional study.It was conducted in a medium-sized public hospital in Distrito Federal (Federal District).The hospital has a total of 20 sectors.

parTicipanTs
One-hundred and ten nursing professionals participated in this study (27 nurses and 83 nursing technicians/assistants).The inclusion criteria were all professionals approved in the selective process of the State Department of Health of the Distrito Federal (Portuguese acronym: SES-DF), and who were actively working at the hospital during the study period.Workers on temporary contract services and those on leave (health leave, vacation, among others) during the study period were excluded.

eThical aspecTs
The study was approved by the Research Ethics Committee of the Health Science Teaching and Research Foundation/SES (FEPECS/SES under number 799.619, 09/22/2014).All were invited to participate by signing the Informed Consent form in accordance with resolution 466/2012 of the National Health Council.

evaluaTion procedures
The complaints of musculoskeletal discomfort were evaluated through application of the Brazilian translated and validated version of the Nordic Questionnaire of Musculoskeletal Symptoms (13) in interview format.The analysis was based on the quantification of frequency of complaints for each body region in relation to the prevalence of symptoms in the 12 prior months, in addition to any work leave related to the reported discomfort.
The Escala de Necessidade de Descanso (Portuguese acronym: ENEDE) is the Brazilian version of the Need for Recovery Scale, translated into Portuguese and adapted for the Brazilian culture (11) .The purpose of the instrument is to measure the need for recovery after a day of work by evaluating the work-induced fatigue and the quality of recovery time.The ENEDE also evaluates short-term effects of fatigue: lack of attention, irritability, social isolation, reduced performance and reduced quality of recovery time after work.The scale contains 11 questions with four alternative answers and equivalent scores for each (always: 3, often: 2, sometimes: 1, and never: 0).The sum of scores of the questions can vary from 0 to 33.Based on scores, is applied a direct rule of three, in which the maximum value is equal to 100 hence transforming it into a 0-100 points scale.For the analysis of residual fatigue, ENEDE values were grouped into two categories, namely: less than or equal to 45 (fewer symptoms and less need for rest), and greater than 45 (greater number of symptoms and greater need for recovery).The higher the score the greater the amount of emotional, cognitive and behavioral fatigue symptoms, and the greater the workers' need for recovery.
The Work Ability Index (WAI) is a Finnish instrument composed of 11 questions concerning the physical and mental demands of work, the health status and resources of workers.The questions are divided into seven main groups, namely: current work ability compared to the lifetime best; work ability in relation to demands of the job; number of diagnosable diseases; estimated work impairment due to diseases; absences from work; own prognosis of work ability; and mental resources.At the end, is calculated a score ranging from 7 to 49, in which: a 7-27 score corresponds to a low work ability; 28-36 score is moderate; 37-43 is good; and 44-49 is excellent work ability.Thus, it provides an assessment of the current and future risk for inability for work.From the score, it is also possible to identify the objective of support measures that must be taken (14) .

daTa analysis
Discomfort complaints were analyzed descriptively and presented according to their frequency of occurrence in the different regions of the body.The Shapiro-Wilk test was applied to verify the normality of data.As the assumptions were not met, non-parametric tests were adopted.The Chisquare test was used to evaluate the association between fatigue scores (ENEDE), presence of discomfort in the previous year and work ability (WAI).In addition, was calculated the odds ratio (OR; confidence interval -CI 95%) to estimate the risk of exposure to residual fatigue (individuals with fatigue and without fatigue) and the presence of musculoskeletal discomfort.
The Mann-Whitney test was used to evaluate differences between groups arising from ENEDE (scores ≤45 or >45), in the following dependent variables: time in the institution and age (both in years).
For the comparison of the residual fatigue (ENEDE) between hospital sectors, a combination of sectors was made by using as criteria the affinity and profile of the work process between professionals' areas of expertise.Thus, three independent groups were generated: Group 1 (Obstetric Center and Maternity); Group 2 (Surgical Clinic, Medical Clinic and Orthopedics); and Group 3 (Adult and Pediatric Emergency Services).For this comparison, was used the Kruskal-Wallis test with the Mann-Whitney post hoc test (total of six multiple comparisons with adjusted significance of 0.8% − p<0.008 so as not to propagate the error of 5%).For data storage and analysis, were used the Epi info 7 and Excel programs.Statistical analysis was performed in the SPSS program (Statistical Package for the Social Sciences, version 20.0), and the significance was set at 5% (p<0.05).

RESULTS
Descriptive data and sociodemographic characterization of participants are presented in Table 1.Participants were 110 professionals in a predominantly female sample (90%), and mean age of 39.47 ± 9.17 years.Most were married with children.The mean workload at the hospital was 38.9 ± 8.6 hours per week, with a mean working time in the institution of 12 ± 9.4 years.Study participants performed activities in several places, namely: Ambulatory Ward 1 and Ambulatory Ward 2, Milk Bank, Center of Sterilized Material, Obstetric Center, Medical Clinic, Surgical Clinic, Maternity, Orthopedics, Pediatrics (hospitalization and emergency room), Emergency Room, Adult and Neonatal Intensive Care Unit (total of 14 sectors).
Of the 110 professionals who answered the item on prevalence of discomfort in arms or neck, 81 (74%) reported having felt discomfort in the arms or neck at some time.Of these, 28 (37.33%) had occasions of sick leave because of this discomfort.However, six participants did not respond to this item.Of the 28 occurrences of sick leave, 57.14% were greater than 15 days.In relation to the prevalence of discomfort in the previous year, 86.24% of respondents presented discomfort in some region of the body.The most prevalent regions were lumbar and thoracic regions (56.38%), followed by cervical region with 51.06%, and ankle and foot with 26.59% (Table 1).
The WAI score demonstrated that most nursing professionals presented good (40.91%) and excellent (20.91%) work ability.However, of the 45 professionals with good work ability, 38 experienced musculoskeletal discomfort in the previous year.All those with low work ability had musculoskeletal discomfort in the previous year.However, there was no significant association between the presence of musculoskeletal discomfort and the Work Ability Index (χ 2 = 0.23; p= 0.97).
The findings related to ENEDE showed that 42.73% of professionals presented fatigue symptoms and hence, a greater need for recovery.However, the association between fatigue and the presence of discomfort was not significant (χ 2 = 1.008 − p=0.315;OR: 1.77 -95% CI [0.57; 5.51]).Among professionals with established fatigue, 95.74% felt musculoskeletal discomfort in the previous year.Among professionals in the group with a score ≤ 45 (57.27% of the total), 77.78% presented discomfort in the previous year.
There was a significant association between residual fatigue and work ability (WAI).Workers with established residual fatigue had a worse WAI classification (χ 2 = 17.7; p=0.003), as shown in Figure 1.
Based on the division of groups by the ENEDE (with fatigue and without fatigue), there was a significant difference in workers' age by indicating that workers with residual fatigue were younger compared to workers without fatigue (p=0.03).Regarding working time in the institution, there was no significant difference between individuals with and without residual fatigue (p>0.05).
Figure 2 shows the findings related to the comparison of ENEDE scores between clustered sectors.There were no significant differences between sectors (p=0.9).

DISCUSSION
Our findings demonstrate the analyzed population consisted mostly of women, which corroborates previous studies (15)(16)(17)(18) .A considerable number of participants has felt discomfort in the arms and neck at some point in their lives.Our findings confirm recent data (19) , which indicate shoulder, neck, and lumbar spine as the regions with higher prevalence of pain in nursing professionals in the percentages of 62.3%, 68% and 71.5%, respectively.These data highlight the fragility of this working class given their exposure to stressors such as dealing with events related to illness and death on a daily basis, shortage of human resources and work instruments, complexity of care, deviation of function, and double shifts.Furthermore, there is influence of ergonomic risk factors such as inadequate work environment, repetitive work and physical effort (20) .
Previous studies have shown that the main causes of work absence of nursing team members are diseases of the musculoskeletal system (15,18,21) .In our study, only 37.33% of professionals who felt discomfort in the arms or neck had a period of absence.However, when considering data from other study, such findings deserve attention (18) .As nurses   play an important role in the supervision of the nursing team, and in some cases, are smaller in number compared to other members of the team, they are on leave less often or take longer to seek care (18) .Another reason of concern was that nurses choose to work in spite of their illnesses (presenteeism), so as not to cause harm to the team (18) .This may explain our findings regarding the high prevalence of discomfort, low number of absences, and high number of absences longer than 15 days.The prevalence of discomfort in the previous year was high (86.43%),with emphasis on the cervical region (56.38%),lumbar and thoracic spine (51.06%), ankle and foot (26.59%), which corroborated other studies (3,22) .The onset of musculoskeletal discomfort can occur by performing activities requiring constant and intense physical exertion, often performed inadequately and under unfavorable conditions (21) .As an example, the prevalence of lumbar pain in nursing professionals was explained by the performance of activities such as transportation and handling of patients, bathing in the bed, handling stretchers, and procedures with asymmetric postures (23) .The prevalence of discomfort in lower extremities can also be explained by remaining in the standing position for a prolonged period.Isometric muscle contractions also occur in static positions, which in turn produce metabolic waste that accumulates in the muscles due to reduced blood circulation and prolonged contraction.This can trigger painful processes or aggravate pain (23) .Another factor possibly associated with the development of discomfort is the lack of physical training due to the sedentary lifestyle.These findings were highlighted in a previous study (1) in which was reported a high rate of workers not practicing any type of physical activity in their daily lives.
According to the present study results, most workers presented a good work ability.This information is in line with findings of another study (22) that evaluated 465 nursing professionals, and verified that 83.2% of them were classified as having good work ability.This finding deserves attention, since out of the 47 individuals evaluated in the present study as having good ability, only seven did not present discomfort in the previous year.There is a significant association between musculoskeletal diseases and reduction of work ability (24)(25)(26) .Hence, there must be special care with measures of support and risk control directed to these professionals with a view focused on the risk of inability in the near future.
Although most evaluated professionals presented higher scores than 36 in the WAI (borderline score between moderate and good ability), the number of workers with a score below this value (moderate and low ability) was substantial (38.18%).This point can be explained by the physical and mental demands in nursing activity.Inadequate physical loads such as lifting and carrying weight, repetitive work and inadequate postures, along with mental loads such as team and leadership conflicts, level of responsibility, long working hours, and lack of professional recognition can result in stressors that wear out and compromise the health of professionals and the work ability (25) .There must be attention to this factor, since it demonstrates the importance of support measures to restore and promote work ability (27) .Multidisciplinary interventions involving actions in the work environment, such as the implementation of physical exercise, health education, behavioral changes and ergonomic measures are greatly important in this context (28) .Furthermore, the integration of these interventions, such as in the Sherbrooke model (29) can determine the success of measures of support and restoration of work ability, and prevent musculoskeletal disorders.
The measurement of fatigue is very important in the scope of health professionals given its consequences in the reduction of commitment and performance of their activities, and the consequent higher risk of accidents (30) .The findings of the present study showed 42.53% of professionals had a ENEDE score > 45 (with residual established fatigue).There may be factors as double work shifts, overtime work and the exchange of leisure for work that have resulted in a shortage of recovery periods.Hence the suggestion for future studies investigating these aspects of daily life (external to work) based on health social determinants in order to check any association between social and family factors and fatigue resulting from occupational activity.
An interesting finding of our study was the presence of greater residual fatigue in nursing professionals of lower age.Similar results were found in a previous study (31) , which showed that the greater the age the lower the physical and psychological exhaustion.The authors (31) argued that younger workers tend to create higher expectations for their performance, are more perfectionists and committed to their work.Moreover, younger professionals take on many functions that do not fit them, and demand more from themselves in order to try to keep up with their expectations.There is also the aspect that experience and professional maturity provide coping strategies for dealing better with conflict situations and work demands (31) .Another factor that may also explain our findings regarding fatigue involves the current labor market condition that imposes great demands on young professionals.From the beginning of the career, there can be an intense search for professional qualification with possible concomitant moments of study and work, besides the financial need imposition leading to accumulation of jobs (32) .
Another important finding was the significant association between the presence of residual fatigue and a lower work ability that corroborates with previous studies (4,6,31) .Our findings indicate that fatigue leads to deleterious influences on states of alertness and surveillance, and can be considered a risk factor for reducing the work ability in nursing professionals.Thus, the fundamental need for a rest period for professionals' recovery from the fatigue accumulated during a work day (3) .If this rest period is not enough, effects of residual fatigue can be "transferred" to the following day and, consequently, accumulation in the long term can lead professionals to falling ill.It is necessary to raise awareness about the deleterious effects of fatigue in nursing professionals, mainly because of shift work effects (9) .
Although in the present study was not found a significant difference of ENEDE scores among the different sectors, previous studies (33)(34) demonstrated that nursing professionals working in emergency sectors are at a higher risk of becoming ill.This was attributed to the profile of the sector that deals with severe or potentially serious patients, who need a faster care service, adequate physical structure and efficient communication among team members.However, nurses face the opposite of these requirements in many cases.In other words, precarious environment, overcrowding, and lack of materials and professionals, together with sector disorganization, prolong and make patient care more difficult, consequently causing greater exhaustion (33)(34) .
Limitations of the present study are the restrictions inherent to the use of questionnaires, such as the memory bias of information regarding the presence of discomfort in the prior 12 months.In addition, because of a logistical impossibility of the authors, there was a restriction in the evaluation of a larger number of nursing professionals working in the night shift.

CONCLUSION
Our findings demonstrated a high prevalence of musculoskeletal discomfort in the previous year among nursing professionals working in the hospital setting.A considerable number of professionals presented greater fatigue and need for recovery, conditions with direct impact on the work ability.An important finding was the presence of fatigue in younger workers.From a practical point of view, the monitoring of fatigue levels is recommended particularly in young nursing professionals for preventing deleterious effects in the long term.

Figure 1 -
Figure 1 -Data regarding the association between the different classifications of the Work Ability Index (WAI) and the Need for Recovery Scale score (ENEDE) -Brasília, DF, 2017.
ICU: Intensive Care Unit; ENEDE: Need for Recovery Scale; WAI: Work Ability Index.