Musculoskeletal pain in operating room nurses: Associations with quality of work life, working posture, socio-demographic and job characteristics

Musculoskeletal pain in operating room nurses: Associations with quality of work life, working posture, socio-demographic and job characteristics

International Journal of Industrial Ergonomics 72 (2019) 330–337 Contents lists available at ScienceDirect International Journal of Industrial Ergon...

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International Journal of Industrial Ergonomics 72 (2019) 330–337

Contents lists available at ScienceDirect

International Journal of Industrial Ergonomics journal homepage: www.elsevier.com/locate/ergon

Musculoskeletal pain in operating room nurses: Associations with quality of work life, working posture, socio-demographic and job characteristics

T

Elnaz Asgharia, Iman Dianatb,∗, Farahnaz Abdollahzadehc, Fariba Mohammadid, Parinaz Asgharie, Mohammad Asghari Jafarabadif, Héctor Ignacio Castelluccig a

Student Research Committee, Faculty of Nursing & Midwifery, Tabriz University of Medical Sciences, Tabriz, Iran Department of Occupational Health and Ergonomics, Faculty of Health, Tabriz University of Medical Sciences, Tabriz, Iran c Faculty of Nursing & Midwifery, Tabriz University of Medical Sciences, Tabriz, Iran d Shohada Hospital, Tabriz University of Medical Sciences, Tabriz, Iran e Razi Hospital, Research Center of Psychiatry and Behavioral Sciences, Tabriz University of Medical Sciences, Tabriz, Iran f Road Traffic Injury Research Center, Tabriz University of Medical Sciences, Tabriz, Iran g Centro de Estudio del Trabajo y Factores Humanos, Escuela de Kinesiología, Facultad de Medicina, Universidad de Valparaíso, Valparaíso, Chile b

ARTICLE INFO

ABSTRACT

Keywords: Operating room Musculoskeletal symptoms MSDs REBA Risk factors

This cross-sectional study evaluated the association of socio-demographic and job characteristics as well as quality of work life (QWL) and working posture with the presence of musculoskeletal pain (MSP) among 144 operating room (OR) nurses in Iran. A questionnaire (including the Nordic Musculoskeletal Questionnaire [NMQ] and the QWL questionnaire) and direct observations of working postures using the Rapid Entire Body Assessment (REBA) method were used. A high prevalence of MSP, particularly in the low back (61.9%), knees (60.5%), ankles/feet (55.8%) and neck (44.9%) were found. The overall mean REBA score of 7.7 suggested that most OR nurses (with posture assessed at action levels 3 and 4) needed an immediate investigation and changes in their working habits and workstations to reduce the risk level. Work-related factors including type of operating room, work shifts (rotating), feeling pressure due to work, total QWL and its dimensions (particularly health and safety, knowledge and esteem needs) and working postures were associated with the presence of MSP in different body regions. Socio-demographic factors including gender (being female) and little or no involvement in sport/physical activity were also independently associated with the occurrence of complaints. The findings emphasise the need for multiple component ergonomic interventions involving the socio-demographic and work-related physical and psychosocial factors for prevention of MSP in this occupational group.

1. Introduction Musculoskeletal pains (MSP) constitute a major problem in both developed and developing countries (Buckle and Devereux, 2002; da Costa and Vieira, 2010; Widanarko et al., 2014; Dianat et al., 2015). The MSP impose a huge direct and indirect burden on people and governments (Brooks, 2006; Woolf et al., 2012). The current burden of MSP is high in all almost countries and is predicted to increase in the future (Brooks, 2006; Hoy et al., 2014). Among the healthcare workers, operating room (OR) nurses are at greater risk for MSP due to excessive levels of physical and bio-

mechanical stresses (both static and dynamic) that they are exposed to during their routine job activities. Static pressures are among the most prevalent job factors in this job which originates from maintaining the same postures for a long period of time (depending on surgery type and duration), awkward postures during surgery and performing continuous repetitive and monotonous tasks and even quick movements in emergencies. This situation can lead to sustained static loading and postural stresses in this group of health care professionals. Dynamic pressures on OR nurses can be associated with job activities that require pushing, pulling, or lifting heavy objects such as parts of a bed, patients and surgery equipment which consequently may lead to the develop-

Corresponding author. E-mail addresses: [email protected] (E. Asghari), [email protected] (I. Dianat), [email protected] (F. Abdollahzadeh), [email protected] (F. Mohammadi), [email protected] (P. Asghari), [email protected] (M.A. Jafarabadi), [email protected] (H.I. Castellucci). ∗

https://doi.org/10.1016/j.ergon.2019.06.009 Received 6 March 2018; Received in revised form 7 May 2019; Accepted 23 June 2019 0169-8141/ © 2019 Elsevier B.V. All rights reserved.

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ment of MSP in this occupational group (Choobineh et al., 2010). Previous research has shown that a number of factors can contribute to the development of MSP. These factors can be categorised as individual, biomechanical, and psychosocial factors (Buckle and Devereux, 2002; da Costa and Vieira, 2010; Widanarko et al., 2014; Dianat et al., 2018; Nourollahi et al., 2018). MSP in nursing personnel might be as a result of inadequate conditions of workplace, organisation, and structure of work (Lelis et al., 2012; Bernal et al., 2015). Generally, the MSP are known to be multifactorial phenomena (Buckle and Devereux, 2002). While genetic and morphological factors are unmodifiable, psychosocial and biomechanical factors are modifiable and can be targeted to reduce the prevalence of MSP in different occupational groups. Although a number of studies have investigated the role of biomechanical, physical, psychosocial or organisational factors in the development of MSP in general nursing personnel (e.g., Trinkoff et al., 2003; Bos et al., 2007; Smith et al., 2004; Smith et al., 2006; Kee and Seo, 2007; Warming et al., 2009; Tinubu et al., 2010; Bernal et al., 2015), less is known about risk factors associated with MSP in a more specific group of hospital employees such as OR nurses (Choobineh et al., 2010; Abdollahzade et al., 2016). Choobineh et al. (2010) conducted a study among hospital OR nurses and found significant associations of perceived physical/psychological demands and manual material handling activities with reported MSP in their subjects. In a study by Moscato et al. (2010), the authors reported that frequency, localisation and intensity of low back pain was associated with age, physical activity and work shift of the OR nurses. Associations of work–family conflict, work interruptions and influence at work with lumbar and cervical pain in OR nurses have also been highlighted recently (Nützi et al., 2015). However, there are still some issues that remain to be addressed. For example, a review of the literature demonstrates that there is limited knowledge regarding the association of quality of work life (QWL) and MSP in OR nurses. The QWL can be considered as an important construct for organisations to attract and retain their employees (Kiernan and Knutson, 1990; Sirgy et al., 2001). The QWL can be defined as the degree to which employees are able to satisfy their various important needs through their performance in the workplace while achieving the organisation's goals (Davis, 1983). The QWL is a concept that covers health and safety, economy, family and social life, esteem, self-actualisation, knowledge and aesthetic needs (Sirgy et al., 2001). Considering the important role of psychosocial factors in the development of MSP, a better understanding of this phenomenon is of great importance. In addition, physical workload of employees during their work should also be taken into account. There are a number of techniques for evaluation of physical workload, of which one is postural analysis. Recording working postures using task-sensitive field techniques is a valuable tool for implementing changes and improving work environments. However, to the authors’ knowledge, working postures of OR nurses has received little attention in the literature. As a consequence, little is known about the association of working posture of individual body parts with the occurrence of MSP in those corresponding sites, and particularly using the Rapid Entire Body Assessment (REBA) method (Hignett and McAtamney, 2000) as a reliable postural analysis tool. Given the multifactorial nature of MSP as well as due to different work practises in other developing nations and changing nature of the work (e.g., rapid changes in surgical procedures, operating room equipment, etc.), further research considering physical, psychosocial and demographic variables would seem worthwhile. Therefore, in an attempt to address this issue, the present work was undertaken to evaluate (1) the QWL status among a sample of OR nurses in Iran, (2) the MSP risk levels associated with OR nurses’ postures, (3) the frequency and severity of MSP among OR nurses, and (4) the association between MSP and their contributing factors (including QWL, working posture, demographic and job characteristics).

2. Methods 2.1. Study design and setting This cross–sectional analytical study was conducted among OR nurses in teaching hospitals of the Tabriz University of Medical Sciences (TUMS) (in two general hospitals and six specialty centres including general, skin and burns, orthopedics, cardiology, gynecology and pediatrics). Inclusion criteria included having at least one year of work experience in operating room (because the outcome variables – musculoskeletal symptoms – were based on the frequency of symptoms during the last 12 months), having an associate degree or higher in operating room technician and/or nursing, and individual's consent to participate in the research. Nurses who had history of previous musculoskeletal surgery and obvious skeletal deformities such as kyphosis and scoliosis, were pregnant or had a known psychiatric disorder were excluded from the study. 2.2. Instruments and outcome measures Instruments used in the study included: (1) standardised Nordic Musculoskeletal Questionnaire (NMQ), (2) Quality of Work Life (QWL) questionnaire, and (3) Rapid Entire Body Assessment (REBA) method. Socio-demographic and job details including age, gender, weight, height, body mass index (BMI), education, marital status, being involved in regular sport/physical activity each week, smoking habits, work experience, number of shifts, daily average work hours, field of study, type of operating room, work shifts, perceived pressure due to work, second job/responsibility, job satisfaction, perceived speed of work were also recorded. The NMQ (Kourinka et al., 1987) was used to collect data on the occurrence of MSP in nine different body parts (neck, shoulders, elbows, wrists/hands, upper back, low back, hips/thighs/buttocks, knees, and ankles/feet). The study participants were asked to indicate if they had experienced any pain or discomfort in the last 12 months prior to the study. Those who reported symptoms were asked to indicate the severity of symptoms using a scale from 1 = very low to 5 = very high. The Farsi (Persian language) version of the NMQ with good reliability and validity (Dianat et al., 2015; Dianat and Karimi, 2016) was used in this research. The QWL questionnaire (Sirgy, 2001) consisted of 16 Likert scale items (from totally disagreed = 1 to totally agreed = 5) and measured seven dimensions including health and safety needs (3 items), economic and family needs (3 items), social needs (2 items), esteem needs (2 items), actualisation needs (2 items), knowledge needs (2 items) and aesthetic needs (2 items). The resulting scores ranged from 16 to 80 with higher scores indicating better QWL. The English version of this questionnaire was translated into Farsi and verified for content validity by a panel of ten faculty members in nursing. The final version of this questionnaire in Farsi was prepared based on the suggestions made and was used in the study. The Cronbach's for this questionnaire was 0.85. The REBA checklist (Hignett and McAtamney, 2000), a reliable and validated observational method, was used for postural analysis in this study. This checklist employs a special scoring method for range of motion of each body part (neck – trunk – legs and shoulders – elbows – wrists) based on different static and dynamic movements, rapid changes and unstable postures. The overall REBA score ranges from 1 to 15, which relates to one of the five action levels: Action level 0 (score of 1: very low risk level that could be overlooked), Action level 1 (scores of 2–3: low risk in which change in position might be needed), Action level 2 (scores of 4–7: moderate risk that necessarily requires a change in position), Action level 3 (scores of 8–10: high risk that requires urgent position change); and Action level 4 (scores of 11–15; high risk level that requires urgent position change). In this present study, the working postures of OR nurses while performing three main activities in their job including retracting, transferring sets and setting up a table 331

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was closely examined. Two investigators observed different body postures during these three work activities and recorded the scores in the REBA checklist. Validity of the REBA checklist was checked through content and face validity, while inter–rater reliability was utilised to ensure the reliability of the measure. Agreement between the two observers (using Kappa coefficient) were 87.1%, 89.1% and 89.8% for retracting, set transfer and table setup activities, respectively. Three REBA scores, including neck score, trunk score and leg score were used in logistic regression analyses in order to evaluate the association between individual body part scores and the reported MSP in the corresponding body region. The overall REBA score as well as the REBA scoring for each body part were also used for general description of the tasks.

Table 1 Demographic and job details of the study participants (n = 144). Variables Gender (n (%)) Male Female Age (mean ± SD) BMI (mean ± SD) Education (n (%)) Associate degree Bachelor degree Master degree Marital status (n (%)) Single Married Regular sport/physical activity (n (%)) Yes No Smoking (n (%)) Yes No Work experience (year) (mean ± SD) Number of shifts (mean ± SD) Daily average work hours (mean ± SD) Field of study (n (%)) Operating room Nursing Type of operating room (n (%)) Orthopedics General Skin and burns Cardiology Pediatrics Gynecology Work shifts (n (%)) Morning only Evening only Rotating Feeling pressure due to work (n (%)) Yes No Second job/responsibility (n (%)) Yes No Job satisfaction (n (%)) Low Moderate High Working very fast (n (%)) Yes No

2.3. Data analysis The data were analysed using the SPSS v.17 (SPSS Inc. Chicago, IL, USA). Normality of the data was approved by the Kolmogorov–Smirnov test. The demographic and other study variables were tabulated as mean (standard deviation − SD) and percentages (%). Neck, low back, knees and ankles/feet were the body regions with the highest prevalence of MSP, and therefore these regions were examined more closely in the present study. Four different regression models were therefore developed for this purpose, each testing one body region. Odds ratios (ORs) and 95% confidence intervals (CIs) were used for description of the association between the prevalence of MSP and study variables. Associations were initially assessed using univariate binary logistic regression analysis and those statistically significant variables in the univariate analyses were subsequently entered in multivariate models (using backward stepwise method) to identify independent variables. For dependent variables and covariates, binary logistic use binary variables and all type of variables, respectively, and therefore no normality was required. In the multivariate analyses, all associations were tested simultaneously using a fixed α = 0.05, suggesting that there was no further need for multiple testing correction. The assumptions of logistic regression models (e.g., presence of outliers and collinearity) were checked and the models’ fit was verified using the Hosmer–Lemeshow goodness–of–fit tests. P < 0.05 was considered as statistically significant for all tests. 2.4. Ethical considerations The research was performed after obtaining permission from the Ethics Committee (IR.TBZMED.REC.1395.1065) from Research Council of the TUMS. Arrangements were made with authorities of the selected hospitals and operating rooms and then investigators visited the study settings and explained the research goals and procedures to the participants. The participation in this study was voluntary, all information was remained confidential and the participants had the right to refuse participation.

29 (19.7) 118 (80.3) 34.6 ± 6.6 24.4 ± 2.9 59 (40.1) 86 (58.5) 2 (1.4) 35 (23.8) 112 (76.2) 21 (14.3) 126 (85.7) 5 (3.4) 142 (96.6) 11.2 ± 6.5 31.7 ± 5.6 8.6 ± 2.0 86 (58.5) 61 (41.5) 33 (22.4) 51 (34.7) 4 (2.7) 20 (13.6) 12 (8.2) 17 (18.4) 19 (12.9) 2 (1.4) 126 (85.7) 128 (87.1) 19 (12.9) 48 (32.7) 99 (67.3) 21 (14.3) 104 (70.7) 22 (15.0) 144 (98.0) 3 (2.0)

level and 80% power, a two–tailed test and using G–Power software, the minimum sample size was determined as 144. 3. Results 3.1. 1. Demographic data

2.5. Study participants

The demographic and job details of the study population are presented in Table 1. One hundred and eighteen women (80.3%) and 29 men (19.7%) participated, whose age ranged from 24 to 52 years (mean = 34.5 years; SD = 6.6 years). The majority of OR nurses were married (76.2%) and had a mean BMI of 24.4 kg/m2 (SD = 2.9 kg/m2, range = 16.0–34.4 kg/m2). Among them, 40.1% had associate degree, 58.5% had bachelor degree and 1.4% had master degree. The majority of OR nurses (85.7%) reported that they were not involved in regular sport and physical activities.

The study participants were selected through cluster sampling. A researcher visited each centre as a separate cluster and took note of personnel ID numbers. The numbers were then selected randomly by a person other than the authors of this study. The obtained numbers were matched with ID numbers in the personnel list and the participants were selected. The number of participants to be selected from each centre was determined as the proportion of eligible nurses of a given operating room divided by the total size of the required sample. Considering the relationship between posture/quality of life and MSP, odds ratio was considered as the main effect size. To determine the sample size, a pilot study was performed on a sample of 30 participants, where odds ratio equal to 1.7 was considered to show the relationship between posture/quality of life and MSP. Given the 95% confidence

3.2. Job characteristics The OR nurses had been working in their current job between 2 and 332

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Table 2 MSP reported by the study participants (n = 147).

Table 4 Distribution of REBA scores for the study participants (n = 144).

Prevalence of symptoms

Pain severity (scale 0–5)

n (%)

Mean (SD)

Body region Neck 66 (44.9) Shoulders 49 (33.3) Upper back 48 (32.7) Elbows 28 (19.0) Low back 91 (61.9) Wrists/hands 46 (31.3) Hips/thighs/buttocks 35 (23.8) Knees 89 (60.5) Ankles/feet 82 (55.8) Any region 136 (92.5) Number of body regions with complaints 0 11 (7.5) 1 18 (12.2) 2 20 (13.6) ≥3 98 (66.7)

3.2 3.2 3.4 3.1 3.5 3.2 3.4 3.3 3.2 –

Body part

(1.0) (1.0) (0.8) (1.0) (0.8) (0.9) (0.9) (0.8) (0.9)

Neck Trunk

Legs

– – – –

Upper arm

28 years (mean = 11.2 years; SD = 6.5 years). They worked between 6 and 12 h a day (mean = 8.6 h; SD = 2.0 h). The number of their work shifts ranged between 24 and 52 shifts per month (mean = 31.7; SD = 5.6), and most of them had rotating shift work (85.7%). All participating nurses had nursing training, among them there were 86 (58.5%) nurses with special training in operation room. The majority of OR nurses (87.1%) reported that they felt pressure because of work and had to work very fast (98%). Only 15% of respondents were highly satisfied with their work.

Lower arm Wrists

Action level

Table 2 show the prevalence and severity of MSP in different body regions reported by the OR nurses. A total of 92.5% of the OR nurses reported some kind of MSP at some time during the 12 months preceding data collection. The percentage of respondents who reported one, two or more locations of pain or discomfort were 12.2%, 13.6% and 66.7%, respectively. The most commonly affected body areas were low back (61.9%), knees (60.5%), ankles/feet (55.8%) and neck (44.9%). The prevalence of knee symptoms was significantly higher in females than in males. The level of severity of complaints was generally between moderate to severe (3 or 4 on the scale of 0–5).

0 1 2 3 4

Table 3 The quality of work life (Total QWL and its dimensions) scores. Min–Max

Health and safety needs Economic and family needs Social needs Actualisation needs Esteem needs Knowledge needs Aesthetic needs Total QWL

8.6 6.0 5.8 5.3 6.0 6.8 5.8 44.6

2.0 2.0 1.5 1.6 1.6 1.6 1.6 8.4

3–15 3–15 2–10 2–10 2–10 2–10 2–10 16–80

Table setup

Set transfer

n (%)

n (%)

n (%)

9 (6.1) 83 (56.6) 55 (37.4) 4 (2.7) 62 (42.2) 64 (43.5) 17 (11.6) 0 (0.0) 67 (45.6) 39 (26.5) 40 (27.2) 1 (0.7) 0 (0.0) 36 (24.5) 75 (51.0) 35 (23.8) 1 (0.7) 0 (0.0) 26 (17.7) 121 (82.3) 1 (0.7) 34 (23.1) 112 (76.2)

2 (1.4) 100 (48.0) 45 (30.6) 5 (3.4) 67 (45.6) 60 (40.8) 15 (10.2) 0 (0.0) 62 (42.2) 45 (30.6) 38 (25.9) 2 (1.4) 0 (0.0) 37 (25.2) 82 (55.8) 27 (18.4) 1 (0.7) 0 (0.0) 38 (25.9) 109 (74.1) 2 (1.4) 37 (25.2) 108 (73.5)

5 (3.4) 64 (43.5) 78 (53.1) 5 (3.4) 48 (32.7) 65 (44.2) 28 (19) 1 (0.7) 41 (27.9) 52 (35.4) 50 (34.0) 4 (2.7) 1 (0.7) 45 (30.6) 59 (40.1) 42 (28.6) 0 (0.0) 0 (0.0) 34 (23.1) 113 (76.9) 2 (1.4) 37 (25.2) 108 (73.5)

REBA score

1 2–3 4–7 8–10 11–15

Risk level

Very low Low Moderate High Very high

Job activity Retracting

Transferring sets

Table set up

n (%)

n (%)

n (%)

0 (0) 1 (0.7) 54 (36.7) 76 (51.7) 16 (10.9)

0 (0) 2 (1.4) 63 (42.8) 55 (37.4) 27 (18.4)

0 (0) 3 (2.1) 73 (49.6) 59 (40.1) 12 (8.2)

Table 4 shows the distribution of REBA scores for each body part for the study participants, while the risk levels based on REBA scores for different nursing activities are presented in Table 5. As can be seen from Table 4, the neck and trunk scores of 2 and 3 for the majority of OR nurses showed that the nurses’ necks and trunks were in ≥20° flexion to the front. The upper arms and wrists scores of the nurses were generally 3, which mean that the upper arms were flexed between 45° and 90° and the wrists were not in neutral position (wrists were in extension of ≥15° and deviated/twisted position). The lower arms score for most nurses was 2, indicating working across midline of the body with elbow flexion < 60° or > 100°. The score of the legs was determined to be within normal limit. The overall mean (SD) REBA score was 7.7 (1.9), which indicates that the OR nurses were generally at high risk of musculoskeletal injury. The percentages of working postures at high (scores of 8–10) or very high (scores of 11–15) risk levels for retracting, transferring sets and table set up activities were 62.6%, 55.8% and 48.3%, respectively (Table 5).

Table 3 presents the scores of the QWL questionnaire for the study population. The total mean (SD) score of the QWL was 44.6 (8.4) (range = 16–80). The Cronbach's alpha for the total QWL and its domains were as follows: total QWL = 0.85, health and safety needs = 0.88, economic and family needs = 0.79, social needs = 0.83, actualisation needs = 0.75, esteem needs = 0.91, knowledge needs = 0.89 and aesthetic needs = 0.93.

SD

Retracting

3.5. REBA assessments of working postures

3.4. QWL

Mean

1 2 3 1 2 3 4 5 1 2 3 4 1 2 3 4 5 6 1 2 1 2 3

Job activity

Table 5 Risk levels based on REBA scores for different nursing activities.

3.3. Prevalence and severity of MSP

QWL

REBA score

3.6. Factors associated with MSP The results of univariate and multivariate logistic regression analyses of factors associated with MSP are shown in Table 6. Gender 333

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Table 6 Univariate and multivariate logistic regression analyses of factors associated with MSP among hospital nurses (n = 144) (*p < 0.05, **p < 0.01). Neck

Low back

Knees

Ankles/feet

OR 1 (95% CI)

OR 2 (95% CI)

OR 1 (95% CI)

OR 2 (95% CI)

OR 1 (95% CI)

OR 2 (95% CI)

OR 1 (95% CI)

OR 2 (95% CI)

0.68 (0.11–4.23)



0.48 (0.19–1.20)



0.24 (0.10–0.58)*

0.59 (0.25–1.38)



Female Ref. Age 1.03 (0.98–1.08) BMI 0.95 (0.85–1.07) Education Associate degree 1.22 (0.62–2.40) Bachelor and higher Ref. Marital status Single 0.63 (0.29–1.36) Married Ref. Regular sport/physical activity Yes 0.35 (0.13–0.91)* No Ref. Smoking No 0.36 (0.03–3.32) Yes Ref. Job experience (year) 1.01 (0.96–1.07) Number of shifts 0.98 (0.93–1.04)

– – –

Ref. 0.97 (0.91–1.03) 0.98 (0.86–1.13)

– – –

Ref. 1.02 (0.97–1.07) 1.05 (0.92–1.14)

0.26 (0.10–0.67)* – – –

Ref. 1.01 (0.96–1.07) 1.05 (0.93–1.19)

– – –

– –

Ref. (0.44–2.28) Ref.

– –

0.91 (0.42–1.97) Ref.

– –

0.86 (0.42–1.74) Ref.

– –



1.31 (0.49–3.54) Ref.



0.62 (0.27–1.45) Ref.



0.87 (0.39–1.94) Ref.





0.44 (0.16–1.23)



0.36 (0.13–0.95)*





Ref.



Ref.



– – – –

2.71 (0.43–8.02) Ref. 0.97 (0.91–1.03) 0.98 (0.91–1.05)

– – – –

4.95 (0.92–6.79) Ref. 1.02 (0.96–1.08) 0.96 (0.90–1.02)

– – – –

Daily work hours Field of study Operating room Nursing Type of operating room Orthopedics

0.85 (0.72–1.01)



0.88 (0.73–1.08)



0.86 (0.71–1.03)

1.19 (0.61–2.32) Ref.

– –

1.09 (0.48–2.47) Ref.

– –

0.27 (0.08–0.89)* 0.25 (0.08–0.78)* 0.07 (0.01–0.88)* 0.22 (0.06–0.84)* 1.13 (0.18–6.88) Ref.

0.26 ) 0.07–0.98)* –

1.02 (0.27–3.80)

Gender Male

General Skin and burns Cardiology

Pediatrics Gynecology Work shifts Morning/evening 0.87 (0.34–2.23) only Rotating Ref. Feeling pressure due to work No 0.43 (0.16–1.16)

0.36 (0.14–0.93)* Ref.



– – – –



1.93 (0.31–9.94) Ref. 1.01 (0.96–1.07) 0.90 (0.85–0.96)* 0.88 (0.74–1.05)

1.41 (0.72–2.73) Ref.

– –

1.06 (0.52–2.15) Ref.

– –



0.60 (0.17–2.08)



0.50 (0.15–1.58)



1.06 (0.31–3.55)



0.54 (0.17–1.71)



0.52 (0.17–1.53)





0.22 (0.02–2.02)



0.68 (0.05–8.00)



0.09 (0.01–1.09)



0.13 (0.02–0.58)* – –

0.53 (0.13–2.07)



0.53 (0.13–2.07)



0.53 (0.14–1.93)



1.13 (0.18–6.88) Ref.

– –

1.13 (0.54–8.99) Ref.

– –

3.14 (0.33–9.49) Ref.

– –



0.34 (0.12–0.92)* Ref.

0.39 (0.14–0.12)* –

1.44 (0.45–0.61)



1.20 (0.43–3.33)



Ref.



Ref.



0.25 (0.09–0.74)* –

0.50 (0.18–1.39)



Ref.



0.28 (0.10–0.76)* Ref.

– –





Yes Second job/responsibility No Yes Job satisfaction Low Moderate High Working very fast No

Ref.



0.30 (0.11–0.83)* Ref.

1.09 (0.54–2.21) Ref.

– –

0.44 (0.16–1.17) Ref.

– –

0.64 (0.05–7.29) Ref.

– –

0.22 (0.02–2.57) Ref.

– –

0.90 (0.27–3.00) 2.36 (0.93–6.01) Ref.

– – –

1.49 (0.38–5.74) 2.23 (0.79–6.25) Ref.

– – –

2.43 (0.92–6.41) 0.73 (0.32–1.69) Ref.

– – –

1.87 (0.72–4.87) 1.09 (0.52–2.28) Ref.

– – –

0.23 (0.12–1.18)



0.50 (0.04–5.75)



4.95 (0.79–12.92)





Yes Sport (h/week) Working in sitting position (h/day) Quality of working life Health and safety needs Economic and family needs Social needs Esteem needs

Ref. 0.83 (0.48–1.43) 1.19 (0.77–1.84)

– – –

Ref. 1.08 (0.61–1.92) 1.21 (0.70–2.08)

– – –

Ref. 0.71 (0.40–1.28) 1.87 (0.86–4.05)

– –

3.34 (0.53–10.70) Ref. 0.59 (0.31–1.12) 1.11 (0.69–1.77)

0.98 (0.83–1.16)





0.83 (0.70–0.99)*









1.13 (0.91–1.41) 0.97 (0.79–1.19)

– –

0.87 (0.66–1.14) 0.90 (0.70–1.16)

– –

1.01 (0.83–1.24) 0.86 (0.70–1.05)

– –

0.82 (0.64–1.07) 0.99 (0.78–1.27)

– –

Aesthetics needs

0.95 (0.78–1.16)



0.95 (0.78–1.16)



0.68 (0.53–0.87)*

0.98 (0.77–1.23) 0.78 (0.63–0.97)* 0.85 (0.68–1.06) 0.80 (0.65–0.98)* 0.81 (0.65–1.00)

– –

Actualisation needs Knowledge

0.78 (0.65–0.93)** 0.81 (0.65–1.02) 0.74 (0.60–0.93)** 0.81 (0.66–1.00) 0.84 (0.68–1.03)

0.81 (0.68–0.96)* 0.84 (0.71–1.00)



0.88 (0.73–1.06)

0.80 (0.64–0.99)* 0.88 (0.73–1.06)

– – – – –



– – –



– – –

(continued on next page) 334

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Table 6 (continued) Neck

Total QWL Posture (REBA scores) Table setup Neck Trunk Leg Set transfer Neck Trunk Leg Retracting Neck Trunk Leg

Low back

Knees

Ankles/feet

OR 1 (95% CI)

OR 2 (95% CI)

OR 1 (95% CI)

OR 2 (95% CI)

OR 1 (95% CI)

OR 2 (95% CI)

OR 1 (95% CI)

OR 2 (95% CI)

0.99 (0.95–1.03)



0.93 (0.73–1.18)



0.93 (0.89–0.98)**



0.94 (0.90–0.98)*



2.22 (1.11–4.42)* – –

1.46 (1.03–2.06)* – –













0.96 (0.60–1.53) –

– –

– 1.08 (0.73–1.61)

– –

– 1.08 (0.73–1.59)

– –

1.11 (0.63–1.95) – –

– – –

– 0.74 (0.46–1.19) –

– – –

– – 1.04 (0.70–1.54)

– – –

– – 0.92 (0.63–1.35)

– – –

1.02 (0.57–1.81) – –

– – –

– 1.16 (0.76–1.76) –

– – –

– – 1.17 (0.92–2.45)

– – –

– – 0.90 (0.61–1.33)

– – –

OR 1 = ORs based on univariate binary logistic regression. OR 2 = ORs based on multivariate binary logistic regression. Significant factors are shown in bold. *p < 0.05, **p < 0.01.

This study also identified underlying QWL dimensions among OR nurses that can help to better understand the needs of employees in their working life. In other words, the QWL is a construct that reflects the well-being of employees at their workplace through fulfilment of their needs. Based on the findings of this study, health and safety, knowledge and esteem needs were found to be more evident than other aspects of QWL. This may have several practical implications for both employees and organisations. For example, health and safety needs (e.g., need for protection from possible ill-health, injury or mental harm) is one of the factors which should be considered in this regard. This means particular attention to both physical (e.g., working postures) and mental (e.g., feeling pressure due to work) aspects of work in this occupation. Knowledge needs (e.g., learning to enhance job and professional skills) is also of particular interest, whereby the employees gain knowledge to avoid misconceptions and erroneous beliefs in their work. The self-esteem needs (e.g., the desire of employees to be accepted/valued by others) are other important aspects of QWL, which may reflect the reward systems and organisation image (e.g., the organisation has a positive image in society). The focus on improving the QWL of OR nurses is not only important to avoid MSP, but is also important from job organisation and design point of view. Therefore, based on these findings, it can be concluded that intervention strategies should be aimed at improving working conditions of nurses through job organisation/re-design, training programmes, etc. to decrease both physical and mental demands among this population. The findings of the present study provide additional evidence that the operating room nursing work is both physically and mentally very demanding. As shown in this study, the most common posture adopted by the nurses while performing their tasks in the operating room was the bending posture of the neck and trunk (> 20° flexion) to the front. Obviously, such an awkward and static working posture can cause high levels of biomechanical risk, which can consequently lead to the development of MSP in this group. This was confirmed by the results of multivariate logistic regression models in our study which indicated that neck posture was a significant factor for neck symptoms. Of concern is also the fact that employees had to sustain this posture for prolonged periods of time (such as work in standing position for a relatively long duration in the operating room). The overall mean REBA score of 7.7 in this study demonstrates that both the manual aspects of the tasks and the design of the workstations in the operating rooms had considerable influence on the postures adopted by the OR nurses. It was found that the level of exposure to musculoskeletal risks was high and very high (with posture assessed at action levels 3 and 4) for more than

(being female), regular sport/physical activity, type of operating room, work shift, feeling pressure due to work, quality of working life and working postures were significantly associated with the presence of symptoms in different body regions in the univariate analyses. The results of multivariate logistic regression analyses demonstrated that gender (being female), type of operating room, work shift, feeling pressure due to work, and working postures were independently associated with the occurrence of complaints in different body regions. Other demographic factors (including age, BMI, education, marital status and smoking habits) and job details (such as job experience, number of shifts, daily working hours, fast working and job satisfaction) were not associated with the reported symptoms. 4. Discussion The results of this study add to the understanding of the working conditions and aspects of working life (through QWL assessments) of OR nursing personnel with respect to the occurrence of MSP and their contributing risk factors. Although the present study is not the first to examine the association of various risk factors with the occurrence of MSP among OR nurses, it expands upon previous work in several important ways. The results provide a more extensive overview of the stressful working situation of the OR nurses and highlight the role of individual (gender and physical activity), physical (working postures), psychosocial (QWL and feeling pressure due to work) and organisational (shift work schedules and type of operation room) factors in relation to the occurrence of MSP in this group of health care professionals. These findings have possible implications not only for the employees’ health and safety, but also for patient outcomes. One of the main findings of the study was that the prevalence of MMS was considerably high, so that the majority (92.5%) of OR nurses reported these complaints, and most of these (86%) reported symptoms in more than one body location. This is generally in agreement with previous epidemiological studies, which have shown a relatively high prevalence of MSP among OR nurses in Iran and in other parts of the world (Choobineh et al., 2010; Moscato et al., 2010; Nützi et al., 2015). These findings highlight that OR nurses are a group of healthcare workers who are potentially at high risk for such symptoms. Low back, knees, ankles/feet and neck were the most commonly affected body areas, respectively, which indicates a relatively high physical demand imposed on both upper and lower limbs. The severity of reported symptoms was also considerable. These findings underline the need for preventive measures in this occupational group. 335

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half of the study participants, which emphasises an immediate investigation and changes in working habits and workstations to reduce the risk level. Among the three different job activities of OR nurses examined in this research, working postures during the retracting activity was found to be more stressful than other activities, although the transferring sets and table setup activities were also not appropriate by themselves. These findings have important implications in terms of education of those nurses who are less aware of the effects of poor working postures during their work and improving the workstation redesign for operating room tasks (e.g., to reduce poor working postures) based on employees’ anthropometry. Such an inappropriate working posture, together with high levels of mental workload (e.g., working under time pressure with no voluntary break during the operations) which are essential requisites of operating room nursing activities, makes this job even more challenging. This was confirmed by the results of logistic regression analyses in this study, which demonstrated that feeling pressure due to work was an independent factor predicting MSP in studied nurses. Other specific interventions aiming at improving work organisation (e.g., through developing strategies to cope with time pressure) are also recommended with a view to helping prevent MSP in this occupation. Regarding the relation of socio-demographic factors to MSP, the results of multivariate regression models demonstrated that gender (being female) was an independent risk factor for the occurrence of knee symptoms among the studied nurses. This is relatively similar to the findings of previous studies conducted among OR nurses (Choobineh et al., 2010; Nützi et al., 2015), which have shown that gender is a significant factor for the development of MSP in this occupational group. Choobineh et al. (2010) reported that female OR nurses were more likely to report shoulder, wrist/hand, low back and ankle/foot symptoms than their male counterparts, while Nützi et al. (2015) found that female OR nurses suffered more intensely from cervical pain than male OR nurses. The results of the present study also indicated that those nurses involved in sport/physical activities were less likely to report neck, knee and ankle/foot symptoms than their other counterparts. This result is also similar to the findings of Moscato et al. (2010), who reported that physical activity was a protective factor for lumbar pain in OR nurses. These findings emphasise the need for consideration of socio-demographic variables, in addition to work-related physical and psychosocial variables, in future analysis of MSP in this group of health care professionals. The results also provide further evidence that other job factors such as the shift work schedules and type of operation room should also be taken into account in relation to the occurrence of MSP. Rotating shift work was found to be associated with increased risk of low back pain among OR nurses. This is also relatively similar to the findings of Choobineh et al. (2010), who reported that those OR nurses working in shift system were at greater risk of developing neck, upper back and knee symptoms than those who were day workers. Nevertheless, there also studies which have shown no relationship between MSP and shift working (Nützi et al., 2015). Additionally, the results revealed that those nurses working in gynecology units were more likely to report neck symptoms than other OR nurses. This may be attributed to the fact that almost all employees in gynecology units were females who were exposed to high levels of physical demands such as patient handling activities (e.g., pregnant women) without mechanical aids and to awkward working postures during their work. These findings might highlight the need for ergonomic interventions to improve the working condition of this group of employees. Finally, there may be some concerns with regard to the small sample size in this study. However, it should be noted that this is not of much concern, because the multivariate analyses have enough power to detect significant associations. Nevertheless, it is possible that a larger sample size would have had the power to detect smaller effects.

5. Conclusions The relatively high prevalence of MSP among the OR nurses suggests that this group of health care professionals are at a great risk for developing MSP. The most frequently reported MSP were, in order of decreasing prevalence, in the low back, knees, ankles/feet and neck, suggesting that both upper and lower limbs were exposed to relatively high biomechanical stresses and physical workloads. The relatively high REBA scores in the study confirmed this finding. This means there is an immediate need to investigate and change the working habits and workstations to reduce the MSP risk level in these employees. The findings also emphasises the need for improving the QWL (particularly health and safety, knowledge and esteem needs) of the OR nurses. Considering the substantial role of OR nurses in health care settings, improved working situation of these employees has the potential for a significant impact on quality of care and patient outcomes. Based on the findings of this study, it can be concluded that multiple component ergonomic interventions involving the socio-demographic and workrelated physical and psychosocial factors may be effective for prevention of MSP in this occupational group. Conflict of interest The authors have no conflicts of interest to disclose. Appendix A. Supplementary data Supplementary data to this article can be found online at https:// doi.org/10.1016/j.ergon.2019.06.009. References Abdollahzade, F., Mohammadi, F., Dianat, I., Asghari, E., Asghari-Jafarabadi, M., Sokhanvar, Z., 2016. Working posture and its predictors in hospital operating room nurses. Health Promot. Perspect. 6, 17–22. Bernal, D., Campos-Serna, J., Tobias, A., Vargas-Prada, S., Benavides, F.G., Serra, C., 2015. Work-related psychosocial risk factors and musculoskeletal disorders in hospital nurses and nursing aides: a systematic review and meta-analysis. Int. J. Nurs. Stud. 52, 635–648. Bos, E., Krol, B., van der Star, L., Groothoff, J., 2007. Risk factors and musculoskeletal complaints in non-specialized nurses, IC nurses, operation room nurses, and X-ray technologists. Int. Arch. Occup. Environ. Health 80, 198–206. Brooks, P.M., 2006. The burden of musculoskeletal disease–a global perspective. Clin. Rheumatol. 25, 778–781. Buckle, P.W., Devereux, J.J., 2002. The nature of work-related neck and upper limb musculoskeletal disorders. Appl. Ergon. 33, 207–217. Choobineh, A., Movahed, M., Tabatabaie, S.H., Kumashiro, M., 2010. Perceived demands and musculoskeletal disorders in operating room nurses of Shiraz city hospitals. Ind. Health 48, 74–84. da Costa, B.R., Vieira, E.R., 2010. Risk factors for work‐related musculoskeletal disorders: a systematic review of recent longitudinal studies. Am. J. Ind. Med. 53, 285–323. Davis, L.E., 1983. Design of new organizations. In: Kolodny, H., Beinum, H.V. (Eds.), The Quality of Working Life and the 1980s. Praeger Publisher, New York, NY, pp. 65–86. Dianat, I., Bazazan, A., Azad, M.A.S., Salimi, S.S., 2018. Work-related physical, psychosocial and individual factors associated with musculoskeletal symptoms among surgeons: implications for ergonomic interventions. Appl. Ergon. 67, 115–124. Dianat, I., Karimi, M.A., 2016. Musculoskeletal symptoms among handicraft workers engaged in hand sewing tasks. J. Occup. Health 58, 644–652. Dianat, I., Kord, M., Yahyazade, P., Karimi, M.A., Stedmon, A.W., 2015. Association of individual and work-related risk factors with musculoskeletal symptoms among Iranian sewing machine operators. Appl. Ergon. 51, 180–188. Hignett, S., McAtamney, L., 2000. Rapid entire body assessment (REBA). Appl. Ergon. 31, 201–205. Hoy, D., March, L., Brooks, P., Blyth, F., Woolf, A., Bain, C., Williams, G., Smith, E., Vos, T., Barendregt, J., Murray, C., 2014. The global burden of low back pain: estimates from the Global Burden of Disease 2010 study. Ann. Rheum. Dis. 73, 968–974 annrheumdis–2013–204428. Kee, D., Seo, S.R., 2007. Musculoskeletal disorders among nursing personnel in Korea. Int. J. Ind. Ergon. 37, 207–212. Kiernan, W.E., Knutson, K., 1990. Quality of Work Life. Quality of Life: Perspectives and Issues. American Association of Mental Retardation, Washington, DC, pp. 101–114. Kuorinka, I., Jonsson, B., Kilbom, A., Vinterberg, H., Sorensen, F.B., Andersson, G., Jorgensen, K., 1987. Standardised nordic questionnaires for the analysis of musculoskeletal symptoms. Appl. Ergon. 18, 233–237. Lelis, C.M., Battaus, M.R.B., Freitas, F.C.T.d., Rocha, F.L.R., Marziale, M.H.P., Robazzi, M.L.d.C.C., 2012. Work–related musculoskeletal disorders in nursing professionals:

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