Musculoskeletal Disorders

Workplace Musculoskeletal Disorders (MSDs) have been recognized as a serious problem for many industries, employees and policy makers. It is even more serious in the nursing profession where work involves carrying and moving sometimes very heavy patients. Apart from the pain and trauma associated with MSDs, productive time lost from work, medical expenses and rehabilitation costs are other financial burdens that many nurses experience. It is estimated that more than 60% of people suffer MSDs at times in their lives [1]. A study carried out by Jeffrey shows that over 350,000 working adults file for some kind of work related injury compensation each year. Many efforts have been made to analyze MSDs in nurses, but the focus has been predominantly on patient handling tasks [1].

Musculoskeletal Disorders Among Nurses

Nurses constitute a critical component of the medical care personnel. They perform more manual handling than other medical cadres and their work involves both direct and indirect services to the patient. The nurse spends more time with the patient than other medical care givers. The nature of nursing work, involves manual handling of patients whereby excessive muscular force or effort is used to lift, move, push, pull, hold and carry patients. It also includes repetitive activities. These constrained working postures, repetitive movement, carrying of heavy patients and performance of other physically demanding tasks make nurses highly prone to MSDs [1,2].

Inadequate staffing is another risk factor that increases the potential for MSDS amongst nurses. Often stressful tasks such as transferring patients from a bed to a chair or vice versa may be done alone and manually due to lack of staff and equipment. Several studies have examined the association between nursing staff levels and workplace injuries and illness [3-5]. These studies analyzed the staffing variables which included the ratio of nurse to patients, the availability of nursing aides to assist in patient transfers and the reported worker injuries. High injury rates were reported in areas with low staffing levels. The low staffing levels make the nurses work for more hours, further increasing the risk of MSDs. This causes increased exposure to physical demands and reduced recovery time between work shifts, resulting in increased MSDs [3]. Engkvist et al. [6], found out that Swedish nurses working over 35 hours were at increased risk of back injuries. Similar findings were documented by Engels et al. [7], in a study carried out in Netherlands. Although many efforts have been made to analyze MSDs in nurses, the focus has been predominantly on patient handling tasks [1].

The Kenya Scenario

At Kenyatta National Hospital, all nurses work for at least 40 hours per week, exposing most of them to MSDs. In Kenya the nurse to population ratio is 8.3 per 10000, which is far below the recommended WHO ratio of 25 per 10000. Despite the large literature on work related MSDs in other parts of the world, not much has been reported in Kenya, where the number of nurses is inadequate resulting in stressed workforce. Relevant risk factors such as the anthropometric data of the nurses, administrative factors and ergonomic factors associated with MSDs, have received little attention. This is despite the fact that nurses work under a variety of work environments in terms of available technology across the world, cultural diversity, anthropometric data variations and work environment, thus leaving a knowledge gap. 

The present study was therefore conducted to address this knowledge gap. The study focused on the prevalence of MSDs amongst nurses and associated demographic, ergonomic and administrative risk factors leading to MSDs.

Research Design

A cross-sectional study design which entailed collection of data from a sample of 314 nurses was conducted at Kenyatta National Hospital. Sampling was conducted in two steps. First, a purposive sampling was used to select the treatments based on the types of patients managed and services offered. This resulted in six different sites namely medical, surgical, paediatrics, Intensive Care Unit (ICU), Accident and Emergency (A&E) and the clinics. Secondly, a simple random sampling was employed to draw the respondents from each treatment. Criteria for eligibility of respondents included nurses who were in full employment and had worked in the nursing career for at least 3 years and those who had no history of an MSD before employment. MSDs were ascertained on the basis of frequent pain and duration, with symptoms persisting for at least 3 days.

Instruments and Variables

A self-administered questionnaire was used to collect demographic, ergonomic and administrative factors associated with MSDs among the hospital nurses. Some aspects of the questionnaire were borrowed from the standardized Nordic questionnaire. Some domains addressed in the questionnaire were similar to those used by Lagerstrom et al. These included the prevalence of MSDs, whether medical advice had been sought and absence from work.

Data Analysis

Both qualitative and quantitative methods were used during the analysis. The information collected was analyzed using the SPSS version 17 computer package. Pearson chi-square analysis with a confidence level of 95% was used to determine the dependence of MSDs on the various variables. Presence of MSDs was measured by the declaration of pain with symptoms persisting for at least 3 consecutive days in a period of one year.

Introduction

 In this paper we present results of the risk factors which included ergonomic factors, in terms of work organization, layout of the work station and physical factors; administrative risk factors; the prevalence of MSDs and the anatomical sites affected. The demographic and employment characteristics variables which encompassed risks associated with age, gender, height, weight, experience and the workplace area were reported in another paper by the same authors, Mailutha et al. [8]. However, for purposes of linkage of materials, some supportive aspects are shared.

Description and Characteristics of the Respondents

As observed from Table 1, majority of nurses fall within the 36-44 years’ age bracket and there is no case above 60 years. This is reasonable finding because according to Kenyan law persons below the age of 18 are minors and are not employable, while the mandatory retirement age is 60 years. Employees have an option of early retirement from the age of 50 years, which explains why the age bracket 55-60 has very few respondents, while there is none in the over 60-year bracket because above retirement age one can only be hired on short term contract, which was excluded in the choice of respondents. A good number opt to retire early so that they can either work in own clinics or get employment in the private sector.

Table 1: Description of the Respondents

Response Rate from Departments

The rate of response attained from the various treatments (departments) of the hospital is shown in Table 2. The number of questionnaires distributed in the specific areas was determined by both the total number and availability of the nurses in each area. The highest response rate was established in the medical department (85.3%), followed by the surgical, paediatric and the clinic departments (84, 82 and 78% respectively) with an average of 82.3% respondents. There was a noteworthy variance in the response rate of the ICU and A&E departments. This is probably due to the frequent rotation of the work shifts noted in these areas, making it difficult to access the nurses. The patients attended to here also required urgent attention, making it almost impossible for the nurses to spare time to fill the forms. The overall response rate was 77.7%.

Table 2: Response Rate According To Departments

77.7% is the overall response rate. Standard deviation is 13.4

Work Experience and MSDs

The results showing the relationship between nurses’ work experience and the prevalence of MSDs indicated that 84.7 and 86.6% of the nurses with 20 and less years of experience, suffered from MSDs in male and female respectively (Table 3). The number of nurses with MSDs was relatively high in this category as compared to those with more years of experience. The highest occurrence of MSDs in the female nurses was observed amongst those who had an experience of 11-20 years (44.4%), whereas in male nurses they occurred more in 0-10 years’ bracket (45.3%). The chi-square statistical test carried out confirmed that MSDs and work experience are independent (male df = 2, χ 2 = 1.63 and p value = 0.26; the female df = 3, χ2 = 1.63, p value = 0.44).

Table 3: The Association of MSDs and Work Experience

p-value for both M and F = 0.20 

The Level MSDs in Departments

The prevalence of MSDs in departments is presented in Table 4. The highest percentages of MSDs were observed in the medical and surgical wards. The cases of MSDs among the male nurses were 36.4% in the medical wards and 21.8% in the surgical wards; whereas the female presented with 19.8% in medical and 30.9% in the surgical wards. The Accident and Emergency department had the least number of MSD cases. The statistical results indicated that the rate of MSDs was not significantly associated with the workplace in both genders (the male and female results were; df = 5, χ2 = 2.23, p value = 0.81 and df = 6, χ2 = 5.61, p value = 0.47, respectively.

Table 4: Ranking of Departments According to Prevalence of MSDs

p value for both genders = 0.94

Ergonomic Risk Factors

The findings indicated that physical factors were the most perceived ergonomic risk factors precipitating MSDs (50%), followed by the layout of the workplace (37%), while work structure was the least perceived factor with 13%. The physical factors frequently mentioned were lifting of patients, carrying out procedures in awkward postures and standing for long hours. In the layout of the workplace, the respondents had problems with the location of the workplace in relation to other departments frequented. The nurses had to walk long distances to deliver and collect reports from their administrative departments, despite their heavy schedules. Other areas of concern in the layout of the workplace were lack of ramps, high reaches and overcrowding of the work areas. 

The workplace environment was also viewed as a contributory factor in the cause of MSDs, where, pressure of work, inadequate communication and poor supervisor-nurse relationship were indicated as frequent occurrences in the workplace.

Prevalence of Musculoskeletal Disorders Among Gender

The prevalence of MSDs among nurses is presented in Table 5. The total number of nurses who suffered from MSDs was 74.2%, where female nurses were the majority with 69.6% and the male nurses accounted for the remaining 30.4%.

Table 5: The Prevalence of MSDs Among The Nurses

Distribution of Musculoskeletal Disorders According to Body Sites

Musculoskeletal disorders were characterized according to the anatomical sites frequently injured. As shown in Table 6, the back had the highest prevalence of MSDs (32.5%), followed by the feet (21.5%) and the neck and shoulder (20.4%). The hands are the least affected (6.3%).

Table 6: Anatomical Sites Identified with MSDs According To Gender, Age, Experience and Department

Two hundred and forty-four (244) nurses out of the 314 responded to the questionnaire, with an overall response rate of 77.7%. The greatest challenge encountered during the study was the nurses’ work shifts which kept on changing within short notices, thus hindering the distribution and collection of the questionnaires. However, we believe this response rate is considered reasonably adequate because from these results, the purpose of the research which is to recognize the magnitude of MSDs and identify the risk causing factors was established. Babbie, ascertains that “a review of the published research literature suggests that a response rate of at least 50% is considered adequate for analysis and reporting; a response of 60% is good; a response of 70% is very good”.

From the study it emerged that more than half of the nurses had a work experience of 3 to 12 years and yet they experienced high levels of MSDs. KNH is also affected by the sluggish formal sector employment growth resulting in low rate of staff employment. This probably explains why there are fewer nurses below 35 years. Statistics indicate that the rate of formal employment is decreasing with time. For example, in the years 1998 and 1999 it was 14.6%, reducing to 12.7% in 2005 and 2006 [9]. The lower rate of MSDs among nurses with more years of experience may be attributed to less patient handling and allocation of more administrative duties to that category of nurses. Arrighi [10], observed lower prevalence of MSDs in older workers who have higher clinical experience. He termed this as “survivor effect”. Survivor effect describes a continuing selection process such as those who remain in an employment tend to be healthier overtime.

The three categories of ergonomic factors perceived as the most common risk factors were the physical factors, layout of the workplace and the organizational structure of the workplace. These are most associated with ease of movement, accessibility of tools and accessories, like locations of the shelves, the weight carried and the working postures. The findings here are in agreement with those reported by Delucia et al. [11], where they reported workplace layout of a nurse’s environment affects his or her walking patterns, time spent walking, visibility of patients and even hand washing. 

Administrative factors were mentioned as major sources of MSDs. The nurses had to walk long distances to deliver and collect reports from their administrative offices despite their heavy schedules, overcrowding of the work areas, pressure of work, inadequate communication and poor supervisor-nurse relationship were indicated as frequent occurrences in the workplace. This is an indication that the hospitals in Kenya are yet to adopt modern communication and management technologies. 

Most of the nurses indicated presence of pain in more than one body area. The major causes of back problems are poor posture and improper lifting techniques [12]. The high prevalence of injury to the back as reported in this study is in accordance with several studies [5,13]. 

The cause of the alleged physical factors is perhaps the high nurse-patient ratio observed in KNH, which may result in inadequate assistance when carrying out tasks such as lifting or transferring patients. The ratio of nurse to population is 8.3 per 10000 against WHO recommendation of 25 per 10000. This is supported by the Kenya Health Workforce Report [14]. According to the report, the ratio of nurses retained in Kenya to the population varies by county with a national ratio of 8.3 per 10,000 populations and the highest ratio of nurses below age 60 to population is Nairobi City County (9.7), while Mandera County has the least (0.1).

Also lack of equipment like hoists and mechanical lifts forced the nurses to lift the patients manually. Garg et al. [15] and Daynard et al. also concur that the availability of mechanical devices has a positive impact on the health of the worker. High risk patient handling tasks vary according to clinical settings. In KNH the majority of patients admitted in the medical and surgical areas are adults who are dependent; thus requiring a lot of manual handling. Several studies have indicated that certain clinical settings especially the geriatrics and long-term settings are risk factors in the causation of MSDs [16]. 

At 74.2 % of the nurses experiencing MSDs, clearly shows that the prevalence of MSDs in Kenya is comparatively high, though not unique. The prevalence of MSDs has varied according to studies but has been generally high in most of the previous studies encountered. Fabunmi et al. [17], in a study from Nigeria, reported that the prevalence of MSDs was 90.7%. A study carried out in Japan by Smith et al. showed that the number was much higher here with 99.9%. In Korea the prevalence was 73.3% [18]. This compares closely with the Kenyan situation. The variations noted in prevalence of MSDs over national boundaries may be a result of organizational differences in work settings, cultural differences in perception of pain and the diverse economic. 

In KNH it was observed that most of the patients who attend the Accident and Emergency department were accompanied by relatives or care givers who assisted to carry out the patient handling tasks. It was also noted that each of the workplaces was associated with specific kinds of challenges because the characteristics of the patients such as age and diagnosis; the layout of the workplace and the type of equipment used in each area differed. Smith et al, also noted that the prevalence of MSDs has variations in different work settings because of the difference in the work tasks. The findings in this study show that ICU has the least number of nurses with MSDs differed from those by Kee & Seo [19] and June & Cho’s [20] which recognized ICU as the area with the highest number of nurses suffering from MSDs. However, Cho’s [20], results indicate that Accident and Emergency department has the least cases of MSDs, which concurred with the results in this study

Musculoskeletal disorders among the nursing personnel in Kenyan hospitals are a major occupational health problem. This study established that 74.2% of all the nurses investigated at KNH suffered from MSDs. The anatomical sites frequently affected were the back, feet and shoulders (32.5%, 21.5% and 20.4% respectively). The authors recommend urgent implementation of administrative, technological and ergonomic interventions for incorporation of safe work procedures in hospitals.

Acknowledgment

The authors acknowledge and appreciate the Kenyatta National Hospital for granting authority to carry out the research within the hospital. We sincerely thank nurses who took their time to fill the questionnaires.

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