Presenteeism and musculoskeletal symptoms among nursing professionals 1

ABSTRACT Objective: to identify the prevalence of musculoskeletal symptoms in two stages (before and after six months of the first stage) and its association with presenteeism among nursing professionals. Method: longitudinal study with quantitative data conducted in a Brazilian teaching hospital with 211 nursing professionals. The instruments used for data collection were: Cultural and Psychosocial Influences on Disability - CUPID Questionnaire, used to identify the musculoskeletal symptoms and the Stanford Presenteeism Scale, used to verify presenteeism. The instruments were validated for Brazilian Portuguese. The study was approved by the Human Research Ethics Committee. Descriptive statistics, Mann Whitney test and regression analysis were used to analyze the data. Results: 158 (74.9%) professionals experienced presenteeism and 151 (71.6%) reported low back pain as musculoskeletal symptom. Professionals with low back pain had lower scores on the presenteeism scale and shoulder pain was related to loss of concentration during work. Conclusion: presenteeism lead to a reduction in work performance and was manifested in the presence of musculoskeletal symptoms. In addition, shoulder pain caused loss of concentration at work.


Introduction
Musculoskeletal disorders are important public health problems in several countries. These disorders can cause functional limitations in adults (1) and may interfere with work and daily life activities, arouse feelings such as impotence, uselessness, abandonment and failure, and generate costs, decrease in or lack of productivity and job losses (2)(3) .
Studies have shown a prevalence of musculoskeletal symptoms higher than 70.0% among nursing professionals (4)(5) . In Brazil, this prevalence is above 80.0% (6)(7) . Among the musculoskeletal symptoms, pain is the most prevalent in nursing professionals, according to studies (5,7) .
Nursing professionals are exposed to occupational hazards that may compromise physical and mental health (8) , interfere with the quality of life of the worker and the quality of care provided to the patient (9) and cause illness, absenteeism, presenteeism and generate costs for the institutions (10) .
Absenteeism is defined as the employee's absence from work, consisting of the period the worker is absent due to some intervening motive. It is related to the frequency or duration of the work time lost when the worker does not attend and it corresponds to the absences when he was expected to be present (11) .
Presenteeism is the condition in which professionals attend the workplace and perform their activities in a non-productive way and without providing a good performance due to diseases and/or problems related to work (12) . It may be related to physical and psychological factors (13) . This phenomenon has been a cause of concern among the working population. Among the nursing staff, it is considered a poorly diagnosed contemporary problem, which can lead to serious consequences and risks for professionals, for the institution and for healthcare users (14) .
Presenteeism affects the quality of work, since it leads to errors and omissions in tasks. It is also considered one of the risk factors for future absenteeism due to illness (10) and it causes restriction in labor productivity, not only in relation to quantity, but also in issues related to the quality of the work produced (15)(16) . It can be caused by health problems such as stress, influenza, cold, allergy, asthma and musculoskeletal pain, which often interfere with work productivity (16) . Professionals in this condition are physically at work, but their attention is scattered, which can cause accidents and eventual adverse events to the patients that are under their responsibility.
Considering that musculoskeletal problems are common among nursing professionals, that presenteeism in nursing work has already been evidenced in other studies (10,(17)(18) and that preventive measures are necessary to minimize these problems, we are motivated to find answers to the following question: do musculoskeletal symptoms in nursing professionals cause presenteeism? Therefore, this study was developed with the objective of identifying the prevalence of musculoskeletal symptoms in two stages (before and after six months of the first stage) and its association with presenteeism among nursing professionals.       The data (pain and presenteeism scores) was compared through the non-parametric Mann-Whitney test. There was difference in the mean of the factor avoiding distraction among the nursing professionals who presented shoulder pain; the mean was 9.10, median 9, minimum 3, maximum 15 and SD of 3.21.

Method
Data from the regression analysis of total presenteeism score, pain in the last month, professional category and age are presented in Table 5.  The regression analysis shown in Table 5 observed 157 participants, since one did not fill age in the questionnaire.  For all variables analyzed, no significant differences were observed in relation to pain.

Discussion
The demographic characteristics of the sample The professional category with the largest number of participants in the first part of the study was nursing assistants, followed by nursing technicians and nurses.
In the second stage, the priority trend was nursing assistants, nurses and nursing technicians. In addition, the presence of musculoskeletal symptoms was higher among the nursing assistants. Studies show a higher prevalence of symptoms among nursing assistants (26) , since these professionals perform several procedures, such as lifting weight, moving and cleaning patients, changing and organizing beds and others tasks that can lead to musculoskeletal symptoms (1,5) .
Among the most prevalent musculoskeletal symptoms, low back pain was the most frequently reported by nursing professionals, followed by neck pain. These results are confirmed in other studies (2,5) .
Of the nursing professionals who experienced presenteeism, the majority were female professionals.
This was also observed in a study conducted in Slovenia (27) .
Regarding the professional category, the presenteeism score was lower among nursing technicians.
Studies conducted to identify presenteeism among nursing professionals found a high prevalence of female professionals (17)(18)20,27) , corroborating the results of this study. Regarding the professional category, a study conducted in Brazil to identify presenteeism among nursing professionals found that the majority were nursing assistants and technicians (10) ; thus, the results of this study are similar to the data in the literature.
Regarding the total presenteeism score observed through the SPS-6, musculoskeletal symptoms related to presenteeism affected mostly the female professionals and the nursing technicians. According to this scale scores, the musculoskeletal problems lead to presenteeism among nursing professionals and influenced the performance of the work activities in relation to avoiding distraction and completing work, all related to the reduction of performance in the work activities. There was a statistically significant difference regarding shoulder pain and avoiding distraction.
The results of the sub-dimensions of the scale showed that the men and the nursing technicians presented lower concentration at work due to musculoskeletal symptoms.
In addition, these symptoms influenced the amount of work done, reducing performance.
A study conducted in a hospital in Portugal evaluated the impact on costs caused by loss of productivity and presenteeism among nursing professionals with musculoskeletal symptoms. The study found that these professionals had higher mean scores in the subdimension avoiding distraction compared to completing work. In addition, the nursing assistants had higher levels of presenteeism in both sub-dimensions (18) .
The present study also measured the association between presenteeism scores and presence of pain in the anatomical regions in the participating nursing Santos HEC, Marziale MHP, Felli VEA.
professionals and found that low back pain was the most frequently reported by these professionals. Data from the literature corroborate the results of this research, indicating that low back pain is associated with presenteeism among nursing professionals (27)(28)(29) .
In addition, a high prevalence of low back pain and presenteeism was identified in other studies (18,27,29) .
The present study found elbow pain as the lowest score on the scale of presenteeism in relation to the total score and the sub-dimensions avoiding distraction and completing work. A difference in the factor avoiding distraction was found for nursing professionals who presented shoulder pain, with a mean score of 9.10.
Thus, it can be confirmed that nursing professionals with shoulder pain had a lower level of concentration at work.
The pain interfered negatively in the work activities of the nursing professionals, reducing their performance at work.
Through the regression analysis, it was possible to identify that nursing professionals with low back pain had a lower score on the presenteeism scale (20.1017), which indicates that the worker had low capacity to concentrate and perform the work when in presence of this pain. Similar data were found in an international study conducted in Slovenia with nursing professionals, in which the score of presenteeism related to low back pain was around 20 (27) .
Female participants presented negative scores in all analysis, except for elbow pain. Besides that, knee pain scored the highest negative score among women.
Therefore, it was verified that presenteeism scores were lower for women than for men.