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Print version ISSN 0103-2100
Acta paul. enferm. vol.25 no.3 São Paulo 2012
Work-related musculoskeletal disorders in nursing professionals: an integrative literature review*
Cheila Maíra LelisI; Maria Raquel Brazil BattausII; Fabiana Cristina Taubert de FreitasIII; Fernanda Ludmilla Rossi RochaIV; Maria Helena Palucci MarzialeV; Maria Lucia do Carmo Cruz RobazziV
IOccupational Therapist. Master's student in Sciences, University of São Paulo at Ribeirão Preto College of Nursing - USP - Ribeirão Preto (SP), Brazil
IIRN. Occupational Health Nursing Specialist, Faculdade de Medicina de São José do Rio Preto - FAMERP - São José do Rio Preto (SP), Brazil
IIIPhysiotherapist. Ph.D. candidate in Sciences, University of São Paulo at Ribeirão Preto College of Nursing - USP - Ribeirão Preto (SP), Brazil
IVPh.D., Professor, General and Specialized Nursing Department, University of São Paulo at Ribeirão Preto College of Nursing - USP - Ribeirão Preto (SP), Brazil
VOccupational Health Nurses. Ph.D. Full Professors, University of São Paulo at Ribeirão Preto College of Nursing - USP - Ribeirão Preto (SP). Brazil
OBJECTIVE: To evaluate evidence of the susceptibility of the nursing staff for Work-Related Musculoskeletal Disorders (WRMD).
METHODS: An integrative review of the literature using the databases: Virtual Health Library (VHL) , VHL Nursing, Scopus and Theses Database of the University of São Paulo (USP), obtained 17 studies.
RESULTS: It was evident that WRMD affect nursing professionals and relate to the inadequate conditions of the workplace, and to the organization and structure of work.
CONCLUSION: It is necessary to invest in preventive programs, improving capabilities, health education, intervention strategies and the organization of existing services.
Descriptors: Cumulative trauma disorders; Musculoskeletal diseases; Nursing; Occupational health; Nursing, team
Work-related musculoskeletal disorders (WMSDs) are isolated or combined problems in the muscles, tendons, synovial membranes (joint tissue) nerves, fascia (connective tissue) and ligaments, with or without tissue degeneration, caused by work. They are characterized by the occurrence of symptoms, concomitantly or not, like: pain, numbness, feeling of heaviness and fatigue. These treacherous injuries generally affect the superior limbs, scapular region around the shoulder and cervical region, but can also affect inferior limbs and are frequent causes of temporary or permanent occupational disabilities(1-2).
Damage caused by WMSDs result from the excessive use of the musculoskeletal system and its inadequate recovery and comprise clinical conditions workers are victims of when they are submitted to inadequate work conditions(3). The origins of these musculoskeletal disorders are multifactorial and complex; they result from a disequilibrium between the requirements the tasks performed at work impose and individual functional abilities to respond to these requirements; and are modulated by the characteristics of work organization(4).
WMSDs produce different levels of functional disability; they result in decreased productivity, increased absenteeism rates, jeopardizing companies' production capacity, and lead to considerable expenses to treat victims and social responsibility indemnity lawsuits(5,6). Besides physical, biomechanical and ergonomic stressors, their etiology includes psychosocial and organizational risk factors, such as high occupational stress, inadequate social support, monotonous activities, anxiety and depression, among others(7).
Nursing workers develop their activities in different places, including hospital institutions, and continuously, demanding constant attention, physical effort, inadequate positions, repetitive movements and weight lifting, which predisposes them to the risk of work-related disease(8); hence, the work routine exposes them to different occupational risk factors. Nursing professionals' work is stressful due to the heavy psycho-emotional burden deriving from the nurse-patient relation, physical requirements, shortage of workers, extended shifts, inadequate work conditions and limited decision making power(8).
Besides unhealthy, work is hard and repetitive and can provoke irreversible physical injuries(9); professionals are victims of musculoskeletal disorders(10) that can result in exhaustion, related to their exposure to physiological burdens, accompanied by painful symptoms in the legs, feet, hands, shoulders, joints, back pain, disk herniation, knee problems, arm/shoulder tendinitis and fatigue(11).
Knowing the determinant aspects of WMSDs in nursing becomes fundamental to understand the causal links of these problems, permitting the implementation of prevention strategies in the workplace and victim treatment and rehabilitation forms(10). Thus, this study was developed to assess scientific evidence about the illness of nursing workers with WMSDs.
As an integrative literature review, this study involved the following steps: establishment of the review hypothesis and objectives; text inclusion and exclusion criteria (sample selection); definition of information to be extracted from the selected texts; result analysis and discussion and presentation of results(12,13). The following research questions were formulated: are nursing team workers victims of WMSDs? How and in what conditions do WMSDs emerge in these workers?
The inclusion criteria were defined as follows: studies published between 1990 and 2010; in Portuguese, English and Spanish; with abstract available in the selected databases, to answer the research questions.
The Health Science Descriptors (DeCS): DORT, transtornos traumáticos cumulativos, enfermagem, trabalhadores were used, as well as their respective translations in English and Spanish. The search was accomplished in July 2010 through online access and the following databases were consulted to select the studies: Virtual Health Library (VHL), Virtual Health Library in Nursing (VHL Nursing), SCOPUS and the University of São Paulo (USP) Dissertation and Thesis Database.
Initially, 29 studies were identified in VHL, 43 in VHL Nursing, 10 dissertations in the USP Dissertation Database and 25 texts in Scopus. All were analyzed by reading the abstracts and selected based on the aim of this review. Forty-five texts were selected from this group (107 texts), 18 of which from VHL, 16 from VHL Nursing, two from the USP Dissertation Database and nine from SCOPUS. Repeated texts, unavailable full versions and texts that did not attend to the aim of this research were excluded. Thus, 17 of the texts and dissertations that complied with the inclusion criteria were analyzed.
To collect information from these studies, a Brazilian validated instrument was used, which aims to guide data collection for integrative and systematic reviews and meta-analyses, based on scientific papers(12), and addresses the following items: identification of original study and its methodological characteristics, assessment of methodological rigor(14), interventions measured and results found. Summary tables were elaborated for the analysis and further synthesis of the included texts.(13)
As the study did not address research involving human beings, no Research Ethics Committee approval was sought.
In this integrative review, 17 studies were analyzed that complied with the inclusion criteria and will be presented next.
Concerning the primary author, 12 were nurses, three physiotherapists, one physician and one did not permit the identification of the author's professional category; 11 were published in nursing journals, three in multidisciplinary journals and one in a physiotherapy journal. Two studies were selected from the dissertation database; six were published in 2010, two in 2009, three in 2008, the same number in 2007, one in 2005 and two in 2004. As for the research design, 11 quantitative studies were found (seven descriptive and cross-sectional, three descriptive and exploratory and one descriptive-retrospective study), four integrative reviews and two qualitative studies. All studies displayed evidence level 6(14), demonstrating weak scientific evidence. Figures 1, 2 and 3 display the synthesis of the papers included in this integrative review.
Nursing work is repetitive, demands physical effort, weight lifting and inadequate postures, associated with the mental stressors that represent risk factors for the occurrence of WMSDs(8-9,15,16). These disorders gain importance in the nursing profession, which is characterized as a high-risk profession for stress and illness(8), with long work periods and demanding high levels of worker responsibility(17,18).
Professionals perform multivariate and fragmented activities, accompanied by an overload and accelerated work rhythm(19); submitted to the high requirements in the work environment, their chances of developing musculoskeletal pain in some body regions are high(20). WMSDs are related with the organization and intensity of the work rhythm, enhancing workers' suffering and often leading to underreporting of data(19). Disinformation exists about the problem, making people hide their symptoms, which ends up jeopardizing a correct diagnosis and treatment(16). Work-related diseases are underreported(19); recognizing, diagnosing and establishing the causal nexus between most diseases and work represents a challenge(15). Nursing work can provoke often irreversible physical injuries, involving partial or permanent leaves of absence and disabilities(9). Consequently, WMSDs are diseases that are difficult to treat and are motives for sick leave(18), representing a limiting factor for hospital work(21).
Concerning the prevalence of pain or musculoskeletal discomfort, a study found that 96.3% of nursing workers referred pain in the previous 12 months and 73.1% in the last 7 days(20). One study involving elderly caregivers, including nursing auxiliaries, showed that, out of 43 subjects, 62.7% referred musculoskeletal pain in the previous month(22). Among the reasons for illness, 59.68% attribute the problem to musculoskeletal problems. Most leaves of absence in nursing were neck pain, effort-related back pain, tendinitis and tenosynovitis(21). A study of Nigerian nurses showed a large proportion of WMSD, more frequent in the back region(23). Another study appointed that the lesions found in nursing workers include carpal tunnel syndrome and neck pain(24).
Among nursing technicians and auxiliaries, WMSDs are more frequent when compared with nurses, as the latter provide more direct care actions(16). Musculoskeletal system diseases ranked second among nursing workers' disorders, who referred higher frequencies for back (71.5%), neck (68%), shoulder (62.3%) and leg pain (54.6%)(15). The work load and having another job were not associated with musculoskeletal pain reports(10); the back region (62.9%) concentrates most pain/discomfort, followed by the back (25.9%) and shoulders (18.5%)(22). More frequent musculoskeletal symptoms among hospital workers were located in the back and neck regions, respectively, during the 12 months and seven days before the start of data collection(21). The work nursing technicians and auxiliaries perform was related with the main complaints of superior limb problems(16). Musculoskeletal disorders in the neck, shoulder or upper and lower back are associated with physical, psychosocial demands and precarious physical conditioning(25). Among nursing auxiliaries, patient care most strongly affected the cumulative burden, due to the time spent to perform these tasks(26).
The physical-pathological process of De Quervain's injury was described in a nursing workers and triggers life changes characterized by painful manifestations, and especially by physical limitations, arousing multiple feelings(27). WMSDs altered the health-disease process, entailing new experiences, not only related to pain deriving from these disorders, but also to alterations like sleep-and-wake pattern changes(28). Health promotion and prevention by companies is the best way to take care of workers' health, including actions that can create ergonomically adequate and healthy environments. Prevention measures represent lower costs if compared to the treatment of a sick worker(18) and also prevent absenteeism.
Preventing these disorders involves the understanding of psychosocial and stress factors in the work environment and helps to develop disease prevention and health promotion strategies for workers, including the further use of technologies to develop activities that demand greater physical force, sporadic pauses during the work day, conflict management and improved organizational climate(20). In this perspective, ergonomic analysis and its application and correction aim to prevent workers' getting ill and losses for the hospital(21).
Intervention strategies that combine organizational aspects of work, adaptations in the physical environment and task characteristics are important(25). The occupational health nursing service should help to prevent and reduce occupational accident and illness levels, particularly WMSDs. Occupational health nurses facilitate employee/employer interaction and can help to bring down absenteeism rates, improve workers' quality of life and minimize costs for the company(18).
Concerning the questions asked for the sake of this research, it was evidenced that WMSDs represent a reality among nursing workers and that these conditions are responsible for illness and sick leaves, often leading to partial or permanent disability, contributing to the occurrence of losses and burdens for employers. Part of the problems is related to inadequate work conditions and work organization and structural factors.
Institutions are responsible for planning their workers' health promotion better, in partnership with trained health professionals, who work by identifying problems, proposing and applying changes and notifying cases, in order to guarantee healthy and productive workers. Investments are needed in prevention programs, training, health education, intervention strategies and organization of existing services. The preventive focus and education guarantee better health for workers, as well as increased productivity and also contribute to reduce the costs and burdens absenteeism causes.
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Maria Lucia Robazzi e Cheila Maíra Lelis
Universidade de São Paulo. Escola de Enfermagem de Ribeirão Preto
Av. Bandeirantes, 3900. Campus da USP
Ribeirão Preto - SP. CEP: 14042-900
E-mail: firstname.lastname@example.org ou email@example.com
Received article 19/09/2011 and accepted 28/01/2012
* This study was developed at the University of São Paulo at Ribeirão Preto College of Nursing - USP - Ribeirão Preto (SP), Brazil.