Work-related illness in nursing: an integrative review

Abstracts

A busca incessante pela realização de diferentes atividades provoca no homem um aumento das cargas laborais, levando ao aparecimento de doenças físicas, psíquicas e emocionais. Resolveu-se buscar evidências científicas sobre as formas de adoecimento pelo trabalho da enfermagem, bem como as formas para o enfrentamento e prevenção ao adoecimento e acidentes de trabalho. Utilizou-se a revisão Integrativa e a pesquisa foi realizada em bases de dados eletrônicas na área da saúde. Os descritores utilizados foram: doença ocupacional, prevenção ocupacional, trabalhador da enfermagem. Encontrou-se 27 artigos. Percebeu-se que os trabalhadores da enfermagem apresentam dores lombares, injúrias músculo-esqueléticas, sofrem acidentes com material pérfuro-cortante, estresse e tensão no trabalho, sofrem com poluição ambiental e dermatites.

Enfermagem; Carga de trabalho; Saúde do trabalhador; Prevenção de doenças

ARTIGO DE REVISÃO

Work-related illness in nursing: an integrative review

Padecimiento por el trabajo en la enfermería: una revisión integral

Renata Perfeito Ribeiro^I; Julia Trevisan Martins^II; Maria Helena Palucci Marziale^III; Maria Lucia do Carmo Cruz Robazzi^IV

^IMaster in Nursing. Doctoral Student, Programa Interunidades, University of São Paulo at Ribeirão Preto College of Nursing. Assistant Professor, Department of Nursing, State University of Londrina. CNPq Fellow. Londrina, PR, Brazil. [e-mail]

^IIPh.D. in Nursing. Adjunct Professor, Department of Nursing, State University of Londrina. Londrina, PR, Brazil. [e-mail]

^IIIFull Professor, Department of General and Specialized Nursing, University of São Paulo at Ribeirão Preto College of Nursing. Coordinator of Núcleo de Estudos Saúde e Trabalho. Ribeirão Preto, SP, Brazil. [e-mail]

^IVFull Professor, Department of General and Specialized Nursing, University of São Paulo at Ribeirão Preto College of Nursing. Coordinator of Núcleo de Estudos Saúde e Trabalho. Ribeirão Preto, SP, Brazil. [e-mail]

Correspondence addressed

ABSTRACT

Man's endless search for methods of performing different activities leads to increased workloads, which eventually result in physical, psychological and emotional conditions. The objective of this study was to seek scientific evidence regarding the types of work-related conditions or illnesses in nursing, as well as the means of coping and preventing occupational diseases and accidents. An integrative review was performed on the electronic health databases using the following descriptors: occupational disease, occupational prevention, and nursing worker. Twenty-seven articles were found. It was realized that nurses have back pain and musculoskeletal injuries, suffer accidents with sharp-edged materials and endure stress and tension at work, in addition to exposure to environmental pollution and dermatitis.

Descriptors: Nursing; Workload; Occupational health; Disease prevention

RESUMEN

La búsqueda incesante de la realización de diferentes actividades provoca en el hombre un aumento de las cargas laborales, acarreando la aparición de enfermedades físicas, psíquicas y emocionales. Se resolvió buscar evidencias científicas sobre las formas de padecimiento por el trabajo de enfermería, así como las formas para su enfrentamiento y prevención del padecimiento y accidentes de trabajo. Se utilizó la Revisión Integral y la investigación se realizó en bases de datos digitales del área de la salud. Los descriptores utilizados fueron: enfermedad laboral, prevención ocupacional, trabajador de enfermería. Se encontraron 27 artículos. Se percibió que los trabajadores de enfermería presentan dolores lumbares, daños músculo-esqueléticos, sufren accidentes con material corto-punzante, estrés y tensión en el trabajo, sufren con la polución ambiental y dermatitis.

Descriptores: Enfermería; Carga de trabajo; Salud laboral; Prevención de enfermedades

INTRODUCTION

Mankind's relationship with work and with himself has always experienced steady and more complex, deeper and sophisticated transformations.

The intense changes lately observed in the world of work have provoked technological innovations, strengthening of economic activities, and alterations of labor processes. These features have contributed significantly towards human beings' search for versatile competencies in order to be able to cope with a wide array of professional activities⁽¹⁾.

This relentless search for ways to accomplish multi-task performances generates in human beings an increase in all types of workloads, leading to the emergence of physical, psychological and emotional diseases.

Concerned with the escalation in labor-related illnesses, in September 1990 the Brazilian Parliament created Federal Law 8.080. This law set out health standards for work and launched health-based processes providing services toward the protection of the worker and his abilities. The law also highlights a number of activities aimed at improving the workers' health status by means of epidemiologic and sanitary surveillance, as well as measures toward the recovery and rehabilitation of individuals who are exposed to work overload and injuries arising from labor conditions⁽²⁾.

In spite of this law, it is believed that nursing professionals who care for other individuals - and who often forget to take care of themselves and their work environment – have been undergoing an accelerated rate of illness and injury due to unfavorable work conditions in the environments where they carry out their duties.

Whenever nursing professionals assist patients, they are exposed to numerous labor-related risks that result from chemical, physical, mechanical, biologic, ergonomic and psychosocial factors, which trigger the emergence of labor-based illnesses and work-related accidents⁽³⁾.

In this perspective, it is crucial that healthcare professionals search for feasible solutions toward the implementation of health-focused promotion interventions, as well as the adoption of preventive measures against diseases⁽⁴⁾.

Bearing these considerations in mind, this study set out with a keen interest in developing an integrative review of the scientific production, aiming at identifying the nurses' triggers for illness and injury worldwide, as well as searching for the strategies applied by this group of professionals to minimize labor-related illness. Such an investigation proposes to provide knowledge and interpretation of academic productions regarding the issue, aiming at contributing toward the development of future research.

OBJECTIVE

To search for scientific evidence that addresses the different triggers for illness/injury in the work of nurses, as well as the methods employed towards coping with and preventing illnesses and labor-related accidents.

METHOD

In order to reach these objectives, the present study elected to use the Integrative Review method, which includes the analysis of any relevant research that provides support for a decision-making process, thus allowing for the incorporation of results into clinic practice. This type of study is used with the intention of developing a strategy towards the identification and analysis of existing health practices, whenever the production of scientific knowledge is not satisfactorily grounded⁽⁵⁾.

The elaboration of an integrative review demands the adoption of stages that display a methodological rigor in the search for evidence on any given subject. These stages are comprised of six phases: to select the issue to be reviewed (guiding issues); to select the pieces of research that will comprise the study's sample; to represent the characteristics of the reviewed research; to analyze the findings in accordance with the inclusion and exclusion criteria established by the project; to interpret the results; and to present and disclose the results^(6-7).

Taking into account the difficulties of nursing work (vulnerability to risks inherent to the performed work; workloads; insufficient number of professionals in comparison to the large number of admitted patients; low income; length of shifts; among others), as presented by nursing professionals, the following guiding issues were shortlisted for the study:

• What are the major causes of illness/injury among nursing professionals in healthcare?

• What would be efficient interventions toward illness prevention processes in nursing work?

The inclusion criteria for the selected articles for this research were as follows: alignment-based descriptive, quantitative-qualitative, quasi-experimental and experimental studies published between 1986 and 2009 in Portuguese, English and Spanish, with abstracts available on the following selected electronic databases: ISI Web of Knowledge; MEDLINE - Medical Literature Analysis and Retrieval System Online; LILACS – Latin American and the Caribbean Literature on Health Sciences; SCOPUS; SciELO - Scientific Electronic Library; and PubMed, a digital database produced by the National Library of Medicine in the bioscience field.

In the search for the selected articles, the applied strategies respected the specificities of each database and used the following descriptors, which are part of the DeCS and MeSH Health Sciences descriptors: occupational disease; occupational prevention; and nursing professional.

The data collection process employed an instrument built to this end by the coordinators of the Health and Labor Study Center (NUESAT/USP). The instrument was evaluated by experts in another study that applied a similar methodology and complied with the methodological recommendations for this type of research⁽⁸⁾. The applied instrument includes the following items: identification of the original article; methodological characteristics of the study; assessment of the methodological rigor; and evaluation of pertinent results. The present study did not apply the item assessment of measured interventions, as it was not part of the objectives of the research.

Personal papers (workbooks, letters and editorials) were excluded from this research, since they do not encompass the required criteria for a scientific research focused on the search for scientific evidence on the issue. Incomplete articles were also discarded.

Articles included in two different databases were taken from the one with the largest amount of articles⁽⁹⁾.

Results were presented in a descriptive format by means of tables, aiming to capture both the evidence of the illnesses affecting nursing professionals, as well as the actions carried out to cope with and prevent occupational diseases.

RESULTS

The present study found 27 articles that complied with pre-established inclusion criteria and were distributed in the selected databases as follows:

• SCOPUS: 61 articles – one article was included;

• LILACS: four articles – two articles were included;

• ISI: 93 articles – three articles were included;

• PUBMED: 496 articles – six articles were included;

• MEDLINE: 260 articles - 15 articles were included; and

• SCIELO: 12 articles – no article was included.

The following table displays the articles selected for this study, presenting the database in which the article was published, as well as the title of the article, authors, year of publication, adopted method, country of origin and research results.

Table 1

From the 27 published articles, the integrative review observed that two (7.4%) of the selected articles were published in 1998; two (7.4%) in 2000; two (7.4%) in 2001; three (11.1%) in 2002; three (11.1%) in 2003; three (11.1%) in 2004; three (11.1%) in 2005; two (7.4%) in 2006; four (14.8%) in 2007; and three (11.1%) in 2008.

Another piece of information related to the time of publication shows that the Brazilian studies are very recent in the literature. The 2001-2008 interval yielded one publication each in the years 2001, 2002 and 2007, and two publications in 2008.

Regarding the type of methodology applied in the articles included in this research, the table clearly shows that two (7.4%) articles are actually controlled randomized clinical studies; two (7.4%) are non-randomized clinical studies; six (22.2%) are case–control studies; one (3.7%) is a cohort methodology-based study; three (11.1%) are descriptive systematic reviews; 11 (40.7%) are descriptive studies; and two (7.4%) are quasi-experimental Studies.

As per the addressed issues, this research found that both Brazilian and American articles deal with problems related to stress, accidents, occupational risks and musculoskeletal pain.

In addition to identifying stress issues and strategies for coping with stress, one Canadian article listed in the research addresses the issue of the use of protective masks in reducing the risk of transmission of disease to nursing professionals.

Studies also observed that the nursing professionals experience back pain and musculoskeletal injuries^{(19,23-24,26-28,30-31)}, revealing that these health problems are related to the posture adopted by the professionals in their work activities.

The integrative review also identified that nursing professionals are vulnerable to accidents with sharp-edged tools (referred to as sharps by nursing professionals, i.e. needles, instruments, scalpel blades), and are at risk of becoming infected with diseases such as hepatitis and Aids^(11-16) as a result of these accidents. Therefore, healthcare professionals must adhere to Standard Precaution Norms, as studies have shown that nurses are at higher risk of occupational accidents due to lack of compliance with Standard Precaution Norms.

In the European Community there has been a trend toward a deeper concern for the physical pain reported by workers, as well as their stress levels. The EU also proposes a course aiming at training workers to cope more effectively with these problems⁽³¹⁾.

Another aspect of this review indicated that mobile emergency teams fully comply with the Standard Precaution Norms, thus minimizing the risks of contamination by body fluids and consequently preventing infections.

The study also showed that the use of exercise, music, relaxation practices⁽²²⁾, and massage therapy⁽²⁵⁾ were employed as means of coping with stress among healthcare workers. These strategies proved to be highly effective in the reduction of stress levels.

On the other hand, two studies selected by this research^(29-35) showed that complementary therapeutic programs were not effective in decreasing the stress levels of professionals.

Two sample studies selected by this research^(17-18) showed that the nursing workers who are exposed to labor-related stress are able to decrease stress levels whenever the presence of an effective supervisor provides them with support in coping with the problem.

The study also concluded that nursing professionals are exposed to environmental pollution⁽¹⁵⁾.

Nursing professionals can also experience hand dermatitis from the continuous use of gloves demanded by the performance of procedures. A study⁽²¹⁾ revealed that a reduction of frequency in the use of protective gloves will prevent long exposure periods to moisture. Thus, the chances of avoiding hand dermatitis increases dramatically.

DISCUSSION

The study highlights an increase in the number of publications regarding occupational diseases from 2003 onwards. This increase was probably due to the increase in absenteeism in the healthcare sector, a phenomenon that was observed by healthcare institutions. In Brazil, this increase may have been identified following the approval of Law 8.080/90, which sets out working conditions concerning the healthcare status of the working class. From then on, problems stemming from the work environment became increasingly evident. In their turn, workers and institutions started seeking improvements in the working conditions and activity practices.

The analyzed data show that the United States leads the publication of research concerning illness/injury issues of healthcare workers with seven (25.9%) publications, followed by Brazil, with five (18.5%) selected articles. The remainder of the articles were published by European countries, Canada and Australia.

In order for a practice to be modified following the results of any research, published research methodologies have to provide a high level of evidence that will support all necessary changes. The levels of evidence employed in integrative and systematic reviews constitute a way of assessing the research produced in a given area of knowledge, in compliance with the chosen methodological alignment applied by the authors, aiming to generate improvements in yet-to-be consolidated issues^(6-38).

Regarding the type of methodology applied in the articles included in this research, the table clearly shows that two (7.4%) articles are controlled randomized clinical studies; two (7.4%) are non-randomized clinical studies; six (22.2%) are case–control studies; one (3.7%) is a cohort methodology-based study; three (11.1%) are descriptive systematic reviews; 11 (40.7%) are descriptive studies; and two (7.4%) are quasi-experimental studies.

The vast majority of the studies listed in this research used a non-experimental research methodology, accounting for 16 (5.9%) studies. The descriptive-based studies were the most frequently applied.

When the classification process for the determination of the level of evidence of the articles is applied, two (7.4%) articles show a level of evidence equal to one; two (7.4%) articles presented a level of three; seven (25.9%) articles showed a level of four; and 16 (59.2%) articles displayed a level of evidence equal to five.

A systematic study on pain reported by nurses⁽³⁶⁾ suggest that controlled randomized studies are necessary for the achievement of significant results regarding the study of pain in healthcare workers.

Back pain was reported by healthcare professionals as the most frequent type of injury. The study confirmed that the largest incidence of back pain in nursing professionals occurs between 20 and 40 years of age, when workers are in their most productive years in terms of highly demanding activities, which favors the emergence of pain and back injuries^(39,40).

As the nursing teams are required to stand for long periods of time in the performance of their duties, these professionals show a greater incidence of back pain, accounting for 80% of work fatigue and causing their work performance to be compromised⁽⁴¹⁾.

This research also showed that sharp-edged materials (sharps) used in several procedures carried out by nursing workers have a high potential for causing infections due to the enormous risks they present, particularly needles as they are most frequently used. Whenever a professional suffers an accident (needlestick injury) provoked by one of these instruments, they experience both a physical and a psychological injury due to the fear of contracting a disease, which can result in risk both to the professional's health and to the institution where he works⁽⁴⁾.

Any accident with a contaminated sharp-edged instrument or needle can result in diseases such as hepatitis B (transmitted by the HBV virus), hepatitis C (transmitted by the HCV virus) and Acquired Immune Deficiency Syndrome, or AIDS (transmitted by the HIV virus). These diseases can cause negative changes in interpersonal relationships both in the private and in the labor realms, thus generating mental and emotional disorders⁽⁴²⁾.

This integrative review also showed that healthcare professionals are exposed to high stress and tension levels in their work environment; the same occurs in nurses working in psychiatric areas. This may result in care being compromised towards the patients they work with⁽²⁷⁾.

Stress can be the triggering factor for several types of diseases. If a diagnosis and adequate treatment are not provided and tension is not relieved, the professional can present illness that may range from deep sorrow to a depressive crisis. In addition to mental disorders, other biological illnesses may impair the worker; for instance, ulcers, arterial hypertension, herpes, and even heart attacks and cerebrovascular accidents. These illnesses may also be connected with the genetic makeup of each individual. Stress does not cause these diseases, but it may reduce the immunological defenses of the organism, thus opening the way to the emergence of other physiological disorders⁽⁴³⁾.

The Worker's Healthcare Promotion Plan clearly highlights that physical exercises are strategies that contribute to the improvement of people's quality of life, improving their mental health, decreasing stress and anxiety in the short-term, assisting with depression and mood imbalances and promoting a better self-esteem in the long-run⁽⁴⁴⁾.

The application of defensive strategies toward combating labor-related stress is quite relevant to everyday life; however, these strategies should not be the only existing method of fighting stress. Whenever these strategies are employed as the only alternatives, they can lead to alienation, giving rise to a deeper suffering and intensifying the professionals' stress levels, ultimately generating imbalances in the work environment⁽⁴⁵⁾.

Still another study affirms that the nursing professionals' private lives – leisure and domestic activities - are negatively affected by back pain⁽⁴⁶⁾.

Healthcare workers are constantly exposed to environmental pollutions⁽¹⁵⁾; however, despite the orientation they receive in the use of mixed microfiber masks, rather than using plain cotton-based ones, or are advised to avoid contact with mercury in healthcare centers, this training is not relevant in decreasing environmental pollution levels.

Due to the increase in the use of latex gloves in the hospital environment as a result of biohazard concerns, the base material used in this protective equipment has been pointed out as being one of the major causes of dermatitis and occupational hives. Such apparent dermatitis in nurses that make frequent use of these materials may be triggered by the latex, the powder applied to the gloves, or to the chemical products added in the production process of the rubber⁽⁴⁷⁾.

Workers may also be infected by microorganisms from patients diagnosed with Severe Acute Respiratory Syndrome (SARS) who are assisted by mechanical ventilators in Intensive Care Units. An effective strategy to prevent this type of infection is to make use of the N-95 mask. However, although one study⁽²⁰⁾ did report that such a strategy is really effective in decreasing the contamination risks for intensive care unit nurses, it also showed that this is not a compelling reduction.

CONCLUSION

In a nutshell, the present integrative review concerning the different illness/injury processes of nursing professionals, as well as the methods of coping with these problems, clearly showed that the majority of the articles focus only on describing the workers' health disorders.

The interventions proposed by some of the analyzed studies do not produce an impact on dealing with the professionals' illness processes, since the vast majority of scientific research studies employ a descriptive-based approach. The levels of evidence, therefore, ultimately do not effectively contribute to the implementation of practical changes.

Some authors clearly intended to implement preventive methods and practical strategies toward coping with the illness process. However, they faced enormous difficulties in convincing nursing professionals to attend training courses and to make the changes proposed by their studies.

This present study aimed to emphasize the need for research that can produce positive impacts on the workers' health status by presenting methodologies that are capable of bringing about scientific evidence regarding the studied issue.

Acknowledgements

Ao Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq), pelo apoio financeiro

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Correspondência:

Renata Perfeito Ribeiro

Rua Santos, 488 - Apto. 64 – Centro

CEP 86020-040 – Londrina, PR, Brasil

Publication Dates

• Publication in this collection
  07 May 2012
• Date of issue
  Apr 2012

History

• Received
  19 Oct 2010
• Accepted
  18 Aug 2011