Work related musculoskeletal disorders in primary health care nurses

    Work related musculoskeletal disorders in Primary Health Care Nurses Tˆania Ribeiro, Florentino Serranheira Ph.D., Helena Loureiro Ph.D. PII: DOI: Reference:

S0897-1897(16)30197-5 doi: 10.1016/j.apnr.2016.09.003 YAPNR 50840

To appear in:

Applied Nursing Research

Received date: Revised date: Accepted date:

23 July 2015 10 September 2016 11 September 2016

Please cite this article as: Ribeiro, T., Serranheira, F. & Loureiro, H., Work related musculoskeletal disorders in Primary Health Care Nurses, Applied Nursing Research (2016), doi: 10.1016/j.apnr.2016.09.003

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ACCEPTED MANUSCRIPT Work related musculoskeletal disorders in Primary Health Care Nurses

Tânia Ribeiro a, Florentino Serranheira b, Helena Loureiro c a

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Authors:

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Community Nurse Specialist, Primary Health Care Unit Penha de França, 1170-201 Lisbon, Portugal b Ergonomist, Ph.D. National Public Health School, New University of Lisbon, CRPH – Centre for Research in Public Health, Avenida Padre Cruz, 1600-560 Lisbon, Portugal; c

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Professor, Ph.D., School of Health Sciences, University of Aveiro (ESSUA), 3810193 Aveiro, Portugal

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*Corresponding author: Tânia Ribeiro, Tel: + 351 963831278; E-mail: [email protected]

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ABSTRACT Background: Work related musculoskeletal disorders (WRMSDs) constitute a serious occupational health problem among registered nurses (RN) all around the world. Its prevalence is mainly associated with nurses’ high physical demands that still remain poorly studied in Primary Health Care (PHC).

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Purpose: To describe nurses’ self-reported symptoms of WRMSDs (mainly discomfort and pain) in PHC, featuring the main work tasks that may have risk factors for its development.

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Methods: A cross-sectional study was developed to identify self-reported WRMSD symptoms by nurses that worked on PHC in Portugal. Nurses answered an online Portuguese version of the Nordic Musculoskeletal Questionnaire (NMQ) (surveymonkey platform). Data was analysed using the Statistical Package for the Social Science (SPSS17) program. Statistical analysis was based on descriptive statistics and associations with the x2 test, Cramér’s V, Mann-Whitney and Kruskal-Wallis test, with a significance level of 5%.

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Results: A sample (n=409), mostly female (84.0%), showed a high prevalence of WRMSDs symptoms in the last 12 months (89.0%). The lower back was the most affected body region (63.1%), followed by cervical, dorsal, shoulders and the wrist/hand. In the same period, absenteeism related to these complaints was high (51.4%) and strongly connected with standing work (48.8%), bending the trunk (42.3%), rotating the trunk (40.6%), applying force with hands or fingers (37.3%), sitting work (36.6%) and repetitive arm movement (34.3%). This study showed associations between the prevalence of WRMSDs symptoms in different body regions and some individual characteristics such as: gender, age, BMI, presence of other pathologies and regular physical exercise.

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Conclusions: This study indicates that, as in other areas of nursing practice, in PHC nurses are also exposed to risk factors that are linked with a high prevalence of WRMSDs symptoms. “Inadequate” and extreme postures sustained for prolonged periods and their repetitiveness will contribute to this occurrence. This shows the need to develop occupational prevention programs to curb this occupational health issue among PHC nurses.

Keywords: Epidemiology; Nursing; Occupational Health; Primary Health Care; Work related

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musculoskeletal disorders symptoms.

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ACCEPTED MANUSCRIPT 1. Introduction Nurses are the most affected healthcare professionals with regards to their health, comfort and safety (Faria, 2008). Because of the specificity of their work tasks and the long duration of tasks

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in health institutions, they are quite vulnerable to various occupational risk factors (Bessa et al.,

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2010; Farias & Zeitoune, 2005). Prolonged exposure to risk factors (which include physical, biological, chemical, ergonomic and psychosocial factors) may contribute to the occurrence of occupational health disorders and the development of occupational diseases of diverse etiology,

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including the WRMSDs (Aguiar, 2009; Faria, 2008; International Council of Nurses [ICN], 2008; Tinubu et al., 2010).

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WRMSDs are a group of disorders confined to muscles, joints, tendons, ligaments, nerves and bones, sometimes including the localized blood circulation system, whose origin or aggravation is mainly due to professional activity and effects of working conditions in which task performance occurs (European Agency for Safety and Health at Work [EASHW], 2010).

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In addition to the physical risk factors connected to the work tasks, there are also individual risk factors, related to each individual’s susceptibility and organizational/psychosocial risk factors (although these occupational risk factors are often addressed separately), whose control is

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critical (EASHW, 2010; National Program Against Rheumatic Diseases: Musculoskeletal Injuries Related to Work, 2008; Nunes, 2006; Malchaire, Cock & Vergracht, 2001; Serranheira,

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Uva & Lopes, 2008).

WRMSDs statistical data in Portugal is scarce, and for that reason it is not possible to know

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accurately its true importance (National Program of Occupational Health [NPOH] 2009-2012; 2009). Although WRMSDs are recognized as relevant occupational diseases and notification is mandatory, the symptoms are undervalued either by the workforce or by the general population. However, the European Survey on Working Conditions, conducted in 2005, revealed that 30.7% of Portuguese workers reported back pain and 28.8% suffered from myalgia (EASHW, 2010). The first epidemiological study of the active Portuguese population regarding the prevalence of WRMSDs (referred to in this context by occupational rheumatic diseases), found that 5.9% of study participants’ employees (24,269 cases) had clinically relevant work-related injuries in 2009 (Cunha-Miranda, Carnide & Lopes, 2010). Nursing work is one of the most perilous occupations in the healthcare sector. Results obtained in studies conducted in several countries show that WRMSDs constitute a serious occupational health problem among nurses throughout the world (Anap, Iyer & Rao, 2013; American Nurses

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ACCEPTED MANUSCRIPT Association [ANA], 2004; Serranheira, Sousa & Uva, 2010; Tinubu et al., 2010; Trinkoff et al., 2003). These conditions have a strong impact in terms of absenteeism, decreased productivity and

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premature retirement, resulting social-economic costs, either direct or indirectly (Nunes, 2006).

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The negative influence of WRMSDs on nurses’ health and quality of life will directly influence their performance, but also indirectly influence the quality of nursing care provided to patients (Anap, Iver & Rao, 2013; Cotrim et al., 2006; EASHW, 2010; ICN, 2008; Tinubu et al., 2010).

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pidemiological investigations highlight the high WRMSDs morbidity rate among nurses. This has been linked to high physical demands that their work tasks require and the conditions in

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which they are developed (Alexopoulos, Burdorf & Kalokerinou, 2003; Anap, Iyer & Rao, 2013; Choobineh, Rajaeefard & Neghab, 2006; Coelho, 2009; Fonseca & Serranheira, 2006; Martins, 2008; Tinubu et al., 2010; Serranheira et al., 2012). The physiologically "inadequate" and extreme postures (outside the intersegmental joint comfort angles) adopted in work tasks involving the mobilization of patients are considered the main risk factors in the aetiology of WRMSDs in nurses. They include repetitive movements such as lifting, transferring and

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repositioning of patients, often performed manually (without the use of mechanical devices), and therefore requiring an increased physical applied force (ANA, 2004; Nelson, 2006; NIOSH,

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2009; Serranheira et al., 2012), sometimes exceeding nurses’ physical capabilities. The sitting position cans also leading to the development of musculoskeletal symptoms. When

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adopted for long periods of time (hours) spinal disc compression is increased, eventually leading to higher loads on the spine. When spine movement is included in sitting posture (for

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instance flexion and rotation of the trunk), together with the absence of work breaks, the physical load on the spine will exponentially increase (particularly in the lower back), causing fatigue, pain and a gradual decrease in ability to work (productivity) (Guedes, 2008; Nunes, 2009). Repetitiveness in nursing tasks resulting from specific work demands, workplace conditions and equipment, namely the repetition of the same actions and movements, adopting postures considered "inadequate" and extreme and/or force applications with the same anatomical regions, for extended periods of time, are the main contributors for nurses’ WRMSDs (Serranheira, Uva & Lopes, 2008). In Portugal, previous studies have shown the high prevalence of WRMSDs symptoms in nurses in recent years and have pinpointed several risk factors and working conditions to which they are exposed. The results of these investigations converge, in general, with strengthening international results, hence the relevance of WRMSDs problem. However, research data is

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ACCEPTED MANUSCRIPT scarce (only some Portuguese studies were found) (Carneiro, Braga & Barroso, 2012; Coelho, 2009; Galego, 2009; Fonseca & Serranheira, 2006; Nelson, 2006; Martins, 2008; Serranheira et al., 2012; Serranheira, Sousa & Uva, 2010) and all data that is currently available refers almost exclusively to nurses working in a hospital context, disregarding other working contexts such as

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nursing at PHC.

In fact, only two studies cited above mention PHC nurses (Carneiro, Braga & Barroso, 2012; Galego, 2009). In addition to similar working risk factors to which nurses are exposed, they also

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added the large number of complex discontinuous requests they have to fulfil over a working day (Aguiar et al., 2009; ICN, 2008). Simultaneously, the contact with a greater diversity of

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caring contexts demand different levels of knowledge and responsibilities; for instance, developing their tasks at the health centre facilities, or at the users’ own homes (home care). A study with a small nurse’s sample gives special emphasis to those that provided home care. This study revealed a high prevalence of musculoskeletal symptoms in these professionals and stated that home care nurses were three times more likely to develop musculoskeletal

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complaints in the lower back (Carneiro, Braga & Barroso, 2012). It is noted that in Portugal, in PHC, a nurse can develop their work activities in different

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contexts, as "inside" of the health center, or "outside", in the patients home (home care) or in institutionalized groups in health centers coverage (like schools). That often happens during the

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same working day and gives rise to different work tasks and WRMSDs risk. The present study aims at describing the RN self-reported WRMSDs symptoms in PHC,

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featuring the major components of the work tasks that may constitute risk factors for its development.

2. Population and methods All 7,508 PHC Portuguese RN on the Portuguese Registered Nurses Board (PRNB) – Ordem dos Enfermeiros – in 2010 were invited to answer a WRMSDs nationwide questionnaire through an advert on the PRNB web site. Nurses who accepted the invitation provided their personal e-mail address and subsequently received an access link to the questionnaire at the “surveymonkey platform questionnaire” webpage. The link allowed respondents either one response at a time or phased responses, according to each nurse’s personal decision. A total of 409 nurses participated (n=409), representing 5.4% of all PHC nurses registered in PRNB.

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ACCEPTED MANUSCRIPT The data collection instrument used is an adaptation of the NMQ (Kuorinka et al., 1987), which is widely used in Portugal and has been previously tested for reliability and validity (Serranheira, Lopes & Uva, 2008). Essentially, this questionnaire kept the original structure of the NMQ and was divided into four main sections: (i) socio-demographic characteristics, for

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instance, gender, age, weight, height and professional category; (ii) self-reference of WRMSDs

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symptoms in nine body areas (cervical, dorsal, lower back, shoulders, elbow, wrist/hand, thighs, knees and ankles/feet); (iii) identification of nurse’s work tasks and their relationship with WRMSDs symptoms and (iv) health status characterization. An observational, quantitative,

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descriptive/exploratory and cross-sectional study was developed. Statistical analysis was based on descriptive statistics and associations with the χ2 test, Cramér´s V and Mann-Whitney and

using SPSS 17.0 version software.

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3. Results

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Kruskal-Wallis, with a significance level of 5% (p ≤ 0.05). The data analyses were carried out

From 409 PHC nurses respondents, 84.0% were female. The mean age was 39.5% (±

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8.8) years, with a minimum age of 23 years and the maximum of 68 years. Most respondents are in the age range between 31 to 40 years and between 41 to 50 years (35.7 % and 35.9 %, respectively). The most frequent occupational category is

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graduated nurses (45.5 %), followed by specialist nurses (26.4 %) and nurses (19.1% ). As for the experience years, most nurses have between 7-20 years of profession (56.7

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%), only 1.5% of respondents had more than 35 years of nursing (Table 1).

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ACCEPTED MANUSCRIPT Table 1 – Distribution of the sample according to variables: “Gender”, “Age”, “Professional category” and “Experience Years.

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19,1 45,5 26,4 8,3 0,7

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17,1 35,7 35,9 11,3

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84,0 16,0

16,9 56,7 24,9 1,5

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VARIABLE Gender (n=407) Female Male Age (n=409) ≤ 30 years 31 a 40 years 41 a 50 years ≥ 51 years Professional Category (n=409) Nurse Graduate Nurse Specialist Nurse Head Nurse Supervisor Nurse Experience Years (n=402) Under 6 years Between 7 and 20 years Between 21 and 34 years More than 35 years

Most of the respondents (89.0%) presented WRMSDs symptoms in one or more body regions in

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the last 12 months. The lower back was the most affected body region (63.1%), followed by the cervical (50.1%) and dorsal region (40.9%). The smaller prevalence of WRMSDs symptoms

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was at the thighs (8.9%) and elbows (7.2%) (Figure 1). In the last seven days, the presence of musculoskeletal complaints was reported by the majority

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of nurses (63.5%). These complaints occurred predominantly in the lower back (32.8), neck (27.1%), dorsal region (22.0%) and shoulders (19.8%) (Figure 1). Half of the respondents (51.4%) (n=208) reported having been unable to perform their usual tasks (absenteeism) in the last 12 months, because they felt discomfort, pain, fatigue and/or edema (WRMSDs symptoms) in one body region at least. These complaints were located predominantly in the dorsal region (35.9%), followed by the lower back (10.8%), neck (7.3%) and shoulders (Figure 1).

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Figure 1 – WRMSDs symptom prevalence (last 12 months and 7 days) and absenteeism (last 12 months).

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The tasks that nurses performed more frequently during the working day (more than 10 times/day) were computerised work (69.6%), wound care (51.5%), evaluation of blood pressure/glucose and others (42.5%), administering medication (29.7%) and home care (11.9%) (Table 2).

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Table 2 – Frequent nursing tasks during a working day.

%

n.º

16

4,1

51

catheters, 208

61,5

36

More than 10 times per day

n.º

%

n.º

%

12,9

53

13, 4

275

69,6

101

29,9

20

5,9

9

2,7

9,9

56

15,3

85

23, 3

188

51,5

64

17,8

111

30,8

78

21, 7

107

29,7

40

9,8

68

18,4

104

28, 2

157

42,5

101

33,3

103

34,0

63

20, 8

36

11,9

Hygiene and comfort in bed

117

84,2

18

12,9

2

1,4

2

1,4

Positioning/moving patients in bed

112

48,3

79

34,1

28

12, 1

13

5,6

108

62,8

48

27,9

11

6,4

5

2,9

Patient bed lifting without mechanical 120 assistance

65,6

45

24,6

13

7,1

5

2,7

Patient bed lifting with mechanical assistance

97

92,4

6

5,7

1

1,0

1

1,0

Patient feeding

96

89,7

7

6,5

2

1,9

2

1,9

Hygiene and comfort in the bathroom

91

91,0

7

7,0

1

1,0

1

1,0

Computerized work Invasive procedures (intubation, indwelling punctures) Wound care Administering medication

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Evaluation of blood pressure/ glucose and others

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Home care

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Transfer or transportation of patients

%

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n.º

6 a 10 times per day

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NURSING TASKS

2 a 5 times per day

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0-1 times per day

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FREQUENCY

Additionally, using the Kruskal-Wallis test, statistically significant differences have been identified between the number of body regions affected by WRMSDs symptoms in the past seven days, the frequency of administering medication (χ2(3) = 11.545; p = 0.009) and wound care frequency (χ2(3) = 15.563; p = 0.001). These differences progress towards a greater frequency of work tasks, leading to an increased number of affected body regions (Table 3).

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ACCEPTED MANUSCRIPT Table 3 – Number of body regions affected in the past 7 days by frequency of daily tasks. f

0 – 1 times per day 2 – 5 times per day 6 – 10 times per day More than 10 times per day

64 108 78 107

Wound care frequency 0 – 1 times per day 2 – 5 times per day 6 – 10 times per day More than 10 times per day

f

χ2

gl

p

1,235 1,493 1,429 1,745

11,545

3

0,009

σ

χ2

gl

p

0,722 1,455 1,298 1,656

1,186 1,372 1,581 1,601

15,563

3

0,001

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36 55 84 187

0,967 1,569 1,234 1,702

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Administering medication frequency

This study shows a relationship, although not statistically significant, between the WRMSDs symptoms and some of the nursing work tasks, namely: ankles/feet complaints and the computerized work (p=0.006) (r=0.177), administering medication (p=0.023) (r=0.162),

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symptoms in shoulders (p=0.043) (r=0.155) and invasive procedures. The most frequent components of the work tasks mentioned by nurses as being strongly related

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with the development of WRMSDs symptoms were: standing work (48.8%), bending the trunk (42.3%), rotating the trunk (40.6%), applying force with hands or fingers (37.3%), sitting work

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(36.6%) and repetitive arm motion (34.3%). These results indicate the tasks and workplaces that nurses’ physical demands allow them to identify the main risk factors for WRMSDs among

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PHC nurses.

Results also showed associations between the prevalence of WRMSDs symptoms in different body regions and individual characteristics, such as: gender, age, Body Mass Index, presence of pathologies and regular physical exercise: 

a greater propensity of female nurses to have WRMSDs symptoms in shoulders (r=0,105; p=0,036) and ankles/feet (r=0,170; p=0,001), compared with male nurses;

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the prevalence of musculoskeletal complaints in shoulders (p=0,032) in nurses aged 41 to 51 years and in the elbows (p=0,040) and dorsal region (p=0,040) at younger ages (between 31-40 years);

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a relationship between WRMSDs symptoms at knees (p=0,011) and Body Mass Index. Nurses being overweight self-reported more musculoskeletal complaints in knees than nurses of standard-weight;

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higher propensity to suffer of any pathology, such as nurses with more advanced age (p=0,0026), Body Mass Index (p=0,014) and weight (p=0,039) and greater time in the profession (p=0,014); a greater number of breaks during the working day and lower absenteeism

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0,167; p=0,021) in nurses who practice physical exercise.

(r= -

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

These results suggest the need to understand individual risk factor contributions in the study of

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the WRMSDs problem among PHC nurses.

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4. Discussion

Results denote a high WRMSDs symptoms prevalence in Portuguese PHC nurses, in last 12 months (89.0%). They were quite similar to other national and international studies carried out in PHC (Carneiro, Braga & Barroso, 2012; Cheung et al., 2006; Coelho, 2009) or other work contexts (Alexopoulos, Burdorf & Kalokerinou, 2006; Choobineh, Rajaeefard & Neghab, 2006;

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Engels et al., 1996; Gurgeira, Alexandre & Filho, 2003; Josephson et al., 1997; Knibbe & Friele, 1996; Magnago, Lisboa & Griep, 2008; Martins, 2008; Tinubu et al., 2010; Simon et al.,

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2008). However, some differences in work context may be related with the WRMSDs

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symptoms prevalence (Table 4).

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ACCEPTED MANUSCRIPT Table 4 - WRMSDs symptoms prevalence in last 12 months: comparison of results from different national and international studies. WRMSDs symptoms prevalence (%)

Dorsal region

Nursing homes for the elderly

33,8

7,9

Josephson et al. (1997)

Hospital

64,0

Gurgeira, Alexandre & Filho (2003)

Hospital

Trinkoff, Brady & Nielsen (2003)

Wrist/ hand

19,5

5,7

30,0

53,0

60,0

-

59,0

21,9

28,6

40,0

24,8

Hospital

32,0

-

24,0

22,0

-

Smith et al. (2004)

Hospital

56,7

38,9

42,8

40,0

-

Fonseca & Serranheira (2006)

Hospital

65,0

37,0

55,0

34,0

30,0

PHC

55,9

51,2

62,9

73,1

30,3

54,9

46,4

36,4

39,8

39,3

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Cheung et al. (2006)

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22,9

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Engels et al. (1996)

Cervical Shoulders region

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Lower back

WORK CONTEXT

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Anatomical Body Regions

STUDY

Hospital

Martins (2008)

Hospital

72,7

32,2

-

-

-

Hospital

44,1

16,8

28,0

12,6

16,2

PHC

64,6

49,0

73,5

49,0

31,3

Hospital/ PHC and others

60,2

44,5

48,6

35,6

28,1

Hospital

48,2

-

33,1

34,6

-

PHC

63,1

40,9

50,1

37,8

28,4

Tinubu et al. (2010)

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Choobineh, Rajaeefard & Neghab (2006)

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Carneiro, Braga & Barroso (2012)

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Serranheira et al. (2012)

Anap, Iyer & Rao (2013) This study (2013)

This study also emphasizes the high prevalence of WRMSDs nurses’ symptoms at the lower back area (63.1%). That agrees with what was generally and empirically evidenced through different studies in the range of all WRMSDs that affect nurses: disorders at the lower back are the most common, although other body regions are also affected. WRMSDs symptoms may influence the high absenteeism level in PHC nurses (51.4%). This is similar to a study conducted by Martins (2008), about the perception of risk of musculoskeletal injuries in nursing task performance. This author reported that occupational accidents associated with WRMSDs were the main contributors to the loss of working days (on average 25.8 days), and the second most frequent type of occupational accidents in nurses (27.2% of references).

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ACCEPTED MANUSCRIPT According to United States Bureau of Labour Statistics (2011), in 2010, the incidence rate of WRMSDs in the USA increased 10.0% compared to 2009 and caused 53.030 days of absence from work.

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Conversely, Fonseca & Serranheira (2006) and Carneiro, Braga & Barroso (2012) demonstrated

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in their research that the majority of nurses were not prevented from doing their normal work, whilst stating a high prevalence of musculoskeletal disorders complaints.

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For some authors the value of absenteeism level is not greater because nurses (mainly due to their own education and self-knowledge) often turn to self-medication as a treatment for WRMSDs symptoms (Martins, 2008). At the same time, the fact that WRMSDs appear

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insidiously or reveal late effects may hinder or prevent nurses to establish a cause/effect relationship between musculoskeletal symptoms and their work tasks and thus limit the adoption of occupational strategies for prevention. These facts undervalue the problem and its real scope is unknown among nurses and may contribute to premature retirement.

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Nurses’ PHC daily physical demands, such as reported in this study, computerised work, wound care, evaluation of blood pressure/glucose/others and administering medication, often require them to repeatedly change their body position from the anatomical best/correct posture to

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provide a successfully task. In fact, typical "inadequate” posture examples involve situations where the work object is above the worker's head or closer to the ground, forcing him/her to

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stand with hands above the head or, conversely, to work bent over or crouched down (Simoneau, St-Vincent & Chicoine, 2013).

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Results confirm that “inadequate” and extreme postures causing a deviation of postural alignment, that are maintained and repeated daily for prolonged periods, such as bending/rotating the trunk and standing work (self-reported by PHC nurses as being strongly related with WRMSDs symptoms), increased the risk of WRMSDs symptoms (Harber et al., 1987 apud Nelson, 2006; Martins, 2008; Moreira & Mendes, 2003) and shows the need to review nurses’ working conditions. It is known that each body position calls for different muscles and shifting the way certain muscles are stimulated provides relief for others, it is evident that there is a need for information aimed at nurses regarding adopting comfortable working positions that allow the distribution of effort by the various body segments in order to minimize physical fatigue. Further research should be conducted, based on techniques and procedures used in ergonomics, in order to allow a detailed study of the type, frequency and duration of body postures for different the work tasks of PHC nurses.

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ACCEPTED MANUSCRIPT This study also evidences associations between nurses’ individual characteristics and WRMSDs symptoms in different body regions which recall the importance of including a review of individual variables in the risk assessment process to allow for successful prevention and intervention, not limited to aspects related with their own working conditions and tasks. In fact,

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individual risk factors are specific characteristics that vary from individual to individual; the

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role and contribution that each of these characteristics has on the origin and/or WRMSDs development causes some controversy in ergonomics and epidemiological literature that should

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be analysed in this context.

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5.1. Limitations

The generalization of the above results should consider the limitations attributed to the crosssectional studies, as they allow the interference of uncontrolled factors. The high propensity of the sample musculoskeletal symptoms can be based on individual factors, for instance, an increased motivation response by direct or indirect contact with WRMSDs symptoms and cases.

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In order to minimize this bias, it is suggested as a future path of research to perform longitudinal

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6. Conclusions

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studies using stratified samples.

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It was found a high number of PHC nurses’ WRMSDs symptoms (89%) that require responsiveness. Self-reported symptoms affect different body regions. Low back symptoms are (63.1%) particularly prevalent in this nurses group. This study adds up to a growing body of evidence and put forward PHC nurses are exposed to diverse risk factors that cause a high prevalence of WRMSDs symptoms related with the nurses’ working tasks. Half of the PHC nurses (51.4%) in this study report work related absenteeism in the last 12 months. Further research should be conducted to establish the epidemiology of WRMSDs among PHC nurses and support the need to develop occupational prevention and control programs in PHC centres that include organizational, technical and even individual measures to promote the active participation of nurses in a process that definitely leads to a change:

WRMSDs

prevention.

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ACCEPTED MANUSCRIPT Conflict of interest: The authors declare that there are no conflicts of interests regarding the publication of this paper. Author Contributions: All authors confirmed they have contributed to the intellectual content

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of this paper.

Acknowledgements: Authors are grateful to all nurses that participated in this study. The authors would also to acknowledge to Portuguese Registered Nurses Board (PRNB) – Ordem

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(Portugal) for providing the data set that was used.

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dos Enfermeiros and Escola Nacional de Saúde Pública, Universidade NOVA de Lisboa

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