Occup. Mod. Vol. 47, No. 1, pp.

25-32,1997
Copyright O 1997 Rapid Science Pubishars for SOM
Printed In Great Britain. Allrightsreserved
0982-748OCB7

Is ergonomic intervention
alone sufficient to limit
musculoskeletal problems in
nurses?

Downloaded from https://academic.oup.com/occmed/article-abstract/47/1/25/1414172 by guest on 21 September 2019

A. K. Burton,* T. L. Symonds,* E. Zinzen,*
K. M. Tillotson,* D. Caboor,* P. Van Royf and J. P. Clarys1
*Spinal Research Unit, The University of Huddersfield, Huddersfield,
HD1 3DH, UK; ^Department of Exp. Anatomy, Vrije Universiteit
Brussel, Laarbeeklaan 103, 1090 Brussels, Belgium

This study retrospectively surveyed 1,216 nurses at hospitals in Belgium and The
Netherlands. Data concerning workloads, musculoskeletal symptoms, work loss and
psychosocial factors were collected by questionnaire. Lifetime prevalence rates for
musculoskeletal problems and low back trouble were significantly lower in the Dutch
hospitals than the Belgian hospitals, but a significantly higher proportion of Dutch
nurses had 'heavy' workloads. Overall, symptoms and work loss in the previous 12
months were not related to workload, nor was the perception that work was causative;
a change of duties because of symptoms was rare (< 3%). The Dutch nurses differed
strikingly from Belgian nurses on the psychosocial variables; they were less depressed
and significantly more positive about pain, work and activity. It is proposed that
ergonomic interventions alone may be sub-optimal in controlling musculoskeletal
problems among nurses The additional provision of psychosocoial information to
challenge misconceptions and encourage self-management is proposed.

Keywords: Attitudes; back pain; beliefs; coping strategies; ergonomics; musculoskeletal disorders;
nursing; occupation; work.

Occup. Mod. VoL 47, 25-32, 1997

Rtawtd 13 November 1995; accepud in final Jbrm 27 Stpumber 1996.

INTRODUCTION tively, with an annual prevalence of 36% and 38%

Musculoskeletal problems in general, and back pain
in particular, are major problems in industrialized
society and are associated with significant costs;1
Leamon2 has stated that low back trouble (LBT) is
often the most expensive work-related injury. Nursing
has one of the highest prevalence rates for back pain
in comparison to other professions.3"6 Stubbs and
Buckle4 found in a retrospective study of 3,912 British
nurses that the annual prevalence was 43%, the point
prevalence was 17% and the annual incidence was
7.7%. These rates are higher than found in the general
British population; point prevalence for males and
females has been reported as 12% and 15% respec-
Correspondence and reprint requests tcr. Dr K. Burton, Spinal
Research Unit, University of Huddersfield, c/o 30 Queen Street,
Huddersfield, HD1 2SP, UK. Tel: (+44) 1484 424329; Fax: (+44)1484
435744; email: kburtonOcJx.compullnk.co.uk.
respectively.7 It has been estimated that approximately
40,000 nurses take a period of sick leave per year due
to back pain in Britain, which amounts to 750,000
working days lost annually.4 The health services in
England and Wales received 1,170 permanent injury
benefit claims and paid out over £5.4 million, as well
as £1 million in temporary injury allowance during
1988/89.8 Venning et al.9 found, in a group of American
nurses, that back injuries accounted for 40% of all
time-loss claims. Stappaerts10 reported a life-time
prevalence of low back problems among 1,775 nurses
in a large Belgian Catholic hospital of 66%. In terms
of absence in the previous 12 months due to a spell
of back pain, 6% of the females and 5% of males took
a period of absence. Back pain is, then, not only highly
prevalent in the nursing profession but is also associ-
ated with considerable costs due to lost working time.
Many epidemiological studies have been carried out
in the nursing profession to identify risk factors asso-
26 Occup. Med. Vol. 47. 1997
ciated with back pain. The most consistently proposed
risk factor has been lifting,5''1" and much of the reported
back injuries in the British health service have been
attributed to manual handling.8 In all occupations in
Britain, 25% of workplace accidents are associated with
manual handling, but in the health service the proportion
is considerably higher with almost 50% of the accidents
in 1985 reported as associated with manual handling.8
Ergonomic interventions have been suggested as a
means of improving the working conditions of nurses
in order to prevent (or reduce) back injuries.4'12
Ergonomics involves looking at how to best fit the
employee to the work tasks required, by critically evalu-
ating existing work practices and providing a rationale
for interventions to effect safer systems of work.12 If,
however, the working environment alone is considered
then there is a risk of neglecting the individual's
psychosocial well-being. The importance of psycho-
social factors in back pain has been shown by Symonds
et a/.13 who found that industrial workers with a history
of LBT had significantly more negative psychometrics
{e.g. pain locus of control, inevitability beliefs and
activity beliefs) than workers who did not have a
history of LBT. A recent intervention study, which
used an educational pamphlet to encourage positive
attitudes and beliefs about pain, work and activity,
achieved a significant reduction in sickness absence in
an industrial environment.14
Few studies, though, have investigated the psycho-
social component of musculoskeletal complaints and
back pain in nurses, which seems surprising when
Berg et a/.,15 as early as 1976, identified that Swedish
nurses perceived their job to be more stressful than
did industrial workers and also stated that they received
less support from colleagues and bosses at work. Others16
have found that psychosocial factors (as opposed to
physical factors) were of primary importance when
differentiating nurses who had experienced a spell of
LBT for at least three consecutive weeks from nurses
who had no history of LBT or who had experienced
LBT for only three days. They measured various
psychosocial parameters of which anxiety, neuroticism
and general health beliefs were most helpful.
The evidence suggests that the nursing profession
is particularly at risk of musculoskeletal problems,
notably affecting the low back, and that there is a
considerable loss of work time. The understandable
focus on ergonomic interventions may not be the
optimal solution to the problem; the negative attitudes
to work shown by nurses15'16 suggests that psychosocial
factors may be important.
The aim of this study was to explore the relationship
between psychosocial parameters, workload and
musculoskeletal problems in nurses. The following
hypotheses were proposed: nurses in departments with
a 'heavy* workload will have relatively high rates of
musculoskeletal problems, back pain and absenteeism;
nurses with 'positive' psychometrics will have relatively
low rates of musculoskeletal problems, back pain and
absenteeism.
MATERIALS AND METHODS
This study forms a discrete part of a larger multi-
disciplinary study of Belgian nurses. In addition to the
parameters concerned here, the studies involved the
measurement of physical, biomechanical and anthropo-
metric characteristics which will be reported elsewhere.
The study was retrospective and involved nurses
from hospitals in Belgium (two academic and two
Catholic hospitals) and The Netherlands (three general
hospitals); 1,783 nurses were given a booklet of
questionnaires by the senior nurse in each department
in 1992. The instructions stressed that the survey was
Downloaded from https://academic.oup.com/occmed/article-abstract/47/1/25/1414172 by guest on 21 September 2019
initiated by the government and was of general interest
to the nursing profession, but did not mention any
special interest in back pain. These booklets contained
a variety of questions related to musculoskeletal
problems (via questions relating symptoms to general
anatomical areas, perceived causation and need for
absence), as well as five psychosocial instruments
measuring different psychosocial dimensions related
to activity, pain coping strategies, pain control, depres-
sion, and work.
The five instruments used were: (1) the Fear-Avoid-
ance Beliefs Questionnaire (FABQ)17 which has two
subscales measuring beliefs about work activities and
beliefs about general physical activities related to back
pain; (2) the Coping Strategies Questionnaire (CSQ)18
which has eight subscales measuring a number of
strategies for coping with pain such as, praying/ hoping,
catastrophizing, or diverting attention; (3) the Pain
Locus of Control (PLC)19 which has two subscales
which measure beliefs about pain control and about
pain responsibility; (4) the Modified Zung Depression
Inventory (MZ)20 which is a measure of depression
and (5) the Psychosocial Aspects of Work (PAW)13
which measures three different work attitudes: job
satisfaction, mental stress and social support.
Because the FABQ, PLC, and CSQ instruments are
concerned specifically with back pain, they were
completed only by nurses with a history of low back
pain; all nurses answered the PAW and MZ instru-
ments. When the booklets were completed they were
returned to the senior nurse of each department within
the seven collaborating hospitals, and then to a central
location for processing.
Workload was categorized on the basis of the hospital
department in which the nurses worked. Estimates of
workload were made from the nurses' responses to
questions concerning the amount of time (minutes per
day) spent on various nursing activities which
previously have been described in an ergonomic
study21 and a job evaluation study.22 Three workload
categories were defined from the number of minutes
per day spent on patient handling tasks. For the whole
sample, the average time per day spent on strenuous
tasks (turning, lifting, helping, etc.) was found to be
160 minutes (SD = 100); a calculation based on half
of the standard deviation was used to categorize levels
of workload. This resulted in a 'heavy' category for
 A K. Burton et a/.: Back and muscutoskeletal problems in nurses 27

which more than 210 minutes (average + % SD) was
spent on the strenuous tasks, a 'moderate' category in
which between 110-210 minutes were spent on strenuous
tasks, and a 'light' category in which less than 110
minutes (average-1/^ SD) were spent on strenuous
tasks. Thus each nurse could be allocated to a workload
category. In order to validate the resultant classifica-
tions, the nurse's perception of workload was compared
with their hospital departments; it transpired, for
example, that orthopaedics and geriatrics fell into the
heavy category; paediatrics and gynaecology were
moderate; outpatients and administration were classed
as light. This classification of departments was then
variance (ANOVA) including Duncan's multiple range
test, and chi-square tests were used where appropriate.
The level of statistical significance was set at 5%.
RESULTS
Description of study population
One thousand two hundred and sixteen nurses (68.2%)
returned the-booklet. The respective responses from
Catholic, Academic and Dutch hospitals were: 72.6%,
66.8% and 68.7%; non-responders were almost exclu-

Downloaded from https://academic.oup.com/occmed/article-abstract/47/1/25/1414172 by guest on 21 September 2019

independently compared with departmental workload
as classified in a standard Belgian 'minimal nursing
plan'. The classification from the present data was
agreed to be representative of nursing workloads, and
reflected departmental workloads previously reported.23
Absence taken, due to musculoskeletal trouble, in
the previous 12 months, was requested on the
questionnaire quantified in days; the nurses were also
asked to state if they had had to change duties because
of their trouble. The nurses' perception of work being
the cause of their symptoms was noted both for recent
trouble (past 12 months) and for past trouble.
sively confined to those who were off-duty at the time
of questioning. The ages ranged from 19-59 years with
a mean of 32 (SD = 7.9) years. Across the three types
of hospital the nurses working in the Catholic hospitals
were on average significantly (p < 0.04), but not sub-
stantially, older (mean = 33.5; SD = 7.7 years) than
the nurses working in either the Academic (mean =
32.1; SD = 7.5 years) or Dutch hospitals (mean =
31.9; SD = 9.2 years). The lowest proportion of male
nurses was in the Catholic hospitals where only 14%
were male, compared to 24% in the Academic hospitals
and 22% in the Dutch hospital (p < 0.05).

Statistical analysis Musculoskeletal symptoms

The seven hospitals were reduced to three categories A history of any musculoskeletal symptoms was
(Academic, Catholic or Dutch) reflecting their social reported by 812 nurses (66.8%), whilst 648 (53.3%)
and administrative structures. The t-test, analysis of had experienced low back pain specifically — some

Table 1 a. Prevalence of a history of musculoskeletal symptoms, history of low back trouble, and the point-prevalence for low back
pain broken down by type of hospital and type of duty; figures given as percentage and number of hospital group

Musculoskeletal symptoms History of low back trouble Current back pain (point prevalence)
Yes No Yes No Yes No

% (n) % (n) % (n) % (n) % (n) % N

Hospital
Academic 67.9 (540) 32.1 (255) 54.3 (432) 45.7 (363) 15.5 (123) 84.5 (672)
Catholic 74.0 (159) 26.0 (56) 58.1 (125) 41.9 (90) 17.7 (38) 82.3 (177)
Dutch 54.9 (113) 45.1 (93) 44.2 (91) 55.8 (115) 15.5 (32) 84.5 (174)
X 2 ;P 18.66; -e 0.001 9.26; 0.009 0.66; ns*
Duties
Heavy 66.6 (353) 33.4 (177) 54.7 (290) 45.3 (240) 40.4 (76) 59.6 (112)
Moderate 66.4 (255) 33.6 (129) 51.6 (198) 48.4 (186) 49.3 (69) 50.7 (71)
Light 69.3 (194) 30.7 (86) 53.9 (151) 46.1 (151) 46.0 (46) 54.0 (54)
Z2:P 0.75; ns* 0.92;; ns* 2.65; ns*

Figures In boW denote significantly lower symptom reporting by the Dutch nurses
•NS - non-slgnlflcant

Table 1 b. Percentage and number of nurses at each type of hospital engaged in the three categories of duty a n d w o r k l o a d . A signifi-
cantly higher proportion of Dutch nurses worked in heavy departments

Academic Catholic Dutch

% % cX, (n)
(n) (n)
Heavy 35.4 (277) 55.2 (117) 6E1.3 (136)
Moderate 35.2 (276) 29.2 (62) 2Z1.1 (46).
Ught 29.4 (230) 15.6 (33) 8 .5 (17)
X2 = 89.8; p < 0.001
28 Occup. Med. VcJ 47. 1997

239 (36.9%) of whom stated they were experiencing a
current spell of LBT at the time of completing the
booklet.
The nurses in the Dutch hospital had a significantly
lower prevalence of a history both of musculoskeletal
symptoms and low back symptoms compared with the
Belgian Academic and Catholic hospitals, but the point
prevalence of LBT symptoms did not significantly
differ across the three types of hospital (Table la).
When looking at the occurrence of symptoms across
workload categories, no significant differences were
found (Table la). However, the distribution of work-
load categories differed significantly across the hospital
Considering the perceived cause of the complaints
at any time; for those with musculoskeletal problems
the trouble was attributed to a 'work incident' by a
little over 50%; these proportions did not differ sig-
nificantly between the hospitals or between workload
categories (Table 2). When looking at low back trouble
alone, the figures were virtually identical. For work
incidents occurring just in the last 12 months, the
perception of work being a cause was somewhat less
(42%). The nurses in the Catholic hospitals were more
likely to have had a work incident in the previous 12
months compared with the other two types of hospital.
Only 31 of those nurses with musculoskeletal symp-
toms (2.9%) had had to change department because

Downloaded from https://academic.oup.com/occmed/article-abstract/47/1/25/1414172 by guest on 21 September 2019

categories; the Dutch nurses were more likely to work
in heavy departments (Table lb). of their problems during the previous 12 months.

Table 2. Perceived causation of musculoskeletal symptoms at any time, together with related need for absence or change of duties,
broken down by type of hospital and type of duty; figures given as percentage and number of responses

Attributed to work Needed absence Needed change of duties

Yes No Yes responses Yes responses

% (n) % (n) % (n) % (n)

Hospital
Academic 50.4 (348) 49.6 (343) 18.3 (129) 2.9 (20)
Catholic 54.3 (100) 45.7 (84) 19.5 (37) 3.6 (7)
Dutch 54.6 (95) 45.4 (79) 18.8 (35) 2.1 (4)
X2;P 1.59; ns* 0 .14; ns* 0.75; ns*
Workload
Heavy 50.9 (236) 49.1 (228) 16.7 (81) 3.1 (15)
Moderate 52.7 (176) 47.3 (158) 18.6 (63) 2.9 (10)
Light 51.9 (121) 48.1 (112) 21.2 (51) 2.6 (6)
Z2;P 0.27; ns* 2.22; ns* 0.16; ns*

ns = no significant difference between the hospital categories or between the workload categories.

Tabl* 3. Mean scores and standard deviations (SD) from responses to the psychosodal instruments broken down by type of hospital:
Academic, n = 795; Catholic, n = 215; or Dutch, n = 206.

Instrument Subscale Academic Catholic Dutch

Mean (SD) Mean (SD) Mean (SD)
MZ Depression 12.8 (7.8) 13.8 (7.8) 11.0 (6.1)
PAW Job satisfaction 25.1 (5.1) 24.5 (5.4) 26.1 (4.2)
Mental stress 15.9 (3.2) 15.4 (3.3) 16.4 (2.7)
Social support 14.2 (3.1) 14.3 (3.1) 15.5 (2.7)
CSQ Catastrophizing 4.7 (5.2) 5.6 (5.1) 3.8 (5.1)
Self statements 20.9 (7.8) 21.5 (7.1) 19.2 (7.5)
Diverting attention 10.0 (7.2) 11.3 (7.3) 10.9 (7.3)
Increasing activity 13.8 (7.3) 14.5 (6.9) 14.3 (7-5)
Ignoring pain 13.6 (7.1) 14.3 (7.2) 14.6 (7.5)
Pain behaviours 16.4 (6.1) 17.1 (5.7) 15.8 (6.1)
Praying/hoping 6.0 (5.6) 7.1 (6.1) 6.0 (5.8)
Pain sensation 6.7 (5.8) 7.1 (5.8) 6.4 (6.2)
FABQ Physical activity 14.6 (5.6) 15.1 (4.8) 12.3 (5.7)
Work activity 18.4 (9.3) 20.1 (9.0) 17.2 (9.1)
PLC Pain control 10.1 (4.4) 11.0 (4.3) 10.6 (4.7)
Pain responsibility 9.6 (2.4) 9.1 (2.4) 9.7 (2.5)

A high score on these Instruments represents abnormal psychometrics, with the exception of PAW scores, where low scores represent negative attitudes.

Figures In bold are significantly different from the other hospitals at the 5% level.
 A. K. Burton eta/.: Back and musculoskeletal problems in nurses 29

Psychosocial profiles Work loss

Statistically significant differences were found between
the hospital types for the psychosocial score means,
and there was a consistent pattern to the data (Table
3). The nurses in the Dutch hospitals were less
depressed (MZ), had more positive attitudes about job
satisfaction, social support and mental stress (PAW),
catastrophized less, used positive coping strategies
(CSQ), and had less fear avoidance beliefs for both
work and physical activity (FABQ). When looking at
workload, there were no more significant differences
in psychosocial scores across the categories than might
be expected by chance alone (Table 4), but heavy
The proportion of nurses having to stay at home due
to musculoskeletal injury in the preceding 12 months
was 18.6%; this proportion was not significantly
different across either the hospitals or workload
categories.
Work incidents occurring in the 12 months prior to
interview, and perceived as a cause of symptoms, were
more frequent in the Catholic hospitals, but there was
no significant difference in the average number of days
lost for these incidents between the hospital types.
Neither were symptomatic work incidents or average
days lost significantly associated with workload, though

Downloaded from https://academic.oup.com/occmed/article-abstract/47/1/25/1414172 by guest on 21 September 2019

departments did show lower job satisfaction (PAW) interestingly the heavy departments had the lowest
and greater fear of work activity (FABQ). absence rate (Table 5).

Table 4. Mean scores and standard deviations (SD) from responses to the psychosocial instruments broken down by categories of work-
load: Heavy, n - 530; Moderate, n » 384; Light, n = 280

Instrument Subscale Heavy Moderate Ught

Mean (SD) Mean (SD) Mean (SD)
MZ Depression 12.9 (7.7) 13.0 (7.9) 11.9 (6.9)
PAW Job satisfaction 24.7 (4.9) 25.5 (5.0) 25.7 (5.1)
Mental stress 15.8 (3.1) 15.9 (3.2) 16.0 (3.4)
Social support 14.4 (3.2) 14.5 (2.7) 14.2 (3.3)
CSQ Catastrophizing 4.8 (5.3) 4.7 (5.3) 4.7 (5.2)
Self statements 20.9 (7.3) 20.8 (8.1) 20.3 (7.7)
Diverting attention 10.7 (7.4) 10.6 (7.5) 9.6 (6.6)
Increasing activity 14.2 (7.6) 14.4 (7.2) 13.1 (6.7)
Ignoring pain 14.4 (7.1) 14.3 (7.3) 12.6 (72)
Pain behaviours 16.9 (5.7) 16.2 (6.0) 16.0 (6.4)
Praying/hoping 6.3 (5.8) 5.6 (5.7) 6.7 (5.4)
Pain sensation 6.8 (6.0) 72 (6.0) 6.0 (5.6)
FABQ Physical activity 14.9 (5.4) 13.7 (5.1) 14.3 (6.4)
Work activity 20.2 (8.9) 16.6 (9.6) 18.1 (9.1)
PLC Pain control 10.7 (4.1) 10.1 (4.8) 10.0 (4.5)
Pain responsibility 9.3 (2.4) 9.9 (2.4) 9.3 (2.5)

A high score on these Instruments represents abnormal psychometrtcs, with the exception of PAW scores, where low scores represent negative attitudes.

Figures In bold are significantly different from the other workload categories at the 5% level.

Table 5. Muscuioskeleta] symptoms attributed to work In the 12 months prior to Interview and the absence taken, broken down by
type of hospital and category of workload

Attributed to work Absence taken (days)

% yes responses Yes responses (n) Mean (SD)

Hospital
Academic 55.4 (320) 23.4 (44.6)
Catholic 66.2 (102) 20.4 (36.5)
Dutch 59.9 (88) 32.7 (42.3)
X 2 :P X2 = 6.14; p < 0.05 ns"
Workload
Heavy 59.7, (230) 20.3 (32.5)
Moderate 57.1 (157) 31.1 (51.3)
Ught 55.7 (113) 26.2 (53.7)
X Z ;P X =1.02; ns* ns1
• ns » no significant difference between the hospital categories or between the workload categories.

Figure In bold denotes a significantly higher proportion of Catholic nurses attributing their symptoms to work.
30 Occup Mod. Vol. 47, 1997
DISCUSSION
This study concerned a large sample of nurses from
different types of hospital in two countries, and has
concentrated on relationships between musculoskeletal
symptoms, in particular low back trouble, and work-
load with the additional consideration of psychosocial
factors.
Some comments about the methodology are perti-
nent in order to estimate the extent to which the
findings can be generalized. The sample was of
volunteers; it involved largely anamnestic data and the
workloads were not measured directly. There was no
evidence that individuals with a history of back pain
were over-represented in the sample, in fact the preva-
lence was slightly lower than a previous report on
Belgian nurses.10 We believe that the sample is repre-
sentative of nurses working in a variety of hospitals
in Belgium and The Netherlands; the numbers are
high and the volunteers came from a typical mix of
departments with a typical sex distribution. Admit-
tedly, anamnestic data is subject to error but we have
concentrated on a global picture which should be little
influenced by forgetfulness or over-estimations. It
would clearly have been preferable to have had formal
task assessments to estimate workload but this was not
practicable in such a large study; that the classifications
from self-assessed workload were in agreement with a
standard protocol suggests that they are adequately
representative of the work for the purposes of the
present investigation. Although previous reports have
found differences between males and females in respect
of symptoms and associated work loss, those differ-
ences have not been substantial. Therefore, we chose
not to analyze males and females separately (even with
such a large sample, the numbers of males would have
left statistical power inadequate); our intention at this
stage was to examine nursing work in general terms.
The prevalence of musculoskeletal problems reported
from this survey includes low back trouble. The fact
that the low back figures were only 10-15% lower than
for all musculoskeletal complaints supports the
contention that the low back is an important site for
possible injury from nursing activities.
The Dutch nurses reported a significantly lower
occurrence both of back trouble and musculoskeletal
problems in general than did the Belgian nurses,
despite the fact that they more frequently worked in
departments with a higher workload. In fact, workload
was not generally associated with a higher occurrence
of symptoms, a higher rate of absence, a greater
perception that work had caused injury, or a greater need
for change of duties due to injury. The proportion of
symptomatic nurses who changed duties was surpris-
ingly low; this may be a reflection of their purported
stoicism,24 or it could reflect a limited opportunity for
redeployment due to specific needs for nursing
specialities in the different hospital departments.
Apart from the workloads, the striking difference
between the Dutch and Belgian nurses was in the
psychosocial domain. The responses from the Dutch
nurses revealed that, on average, they were significantly
more positive on a range of psychosocial measures,
notably those concerned with attitudes towards work
and activity; they also showed less depressive tendencies
and had more positive pain coping strategies. It is
possible that the Dutch nurses, perhaps because of
their positive attitudes and beliefs, simply did not
report problems to the same extent as the Belgian
nurses. It has been found that reporting of back pain
by British nurses increased between 1983 and 1993,25
following an increased awareness of back trouble by
virtue of the adoption of the European Directive
90/269/EEC on the manual handling of loads sometime
Downloaded from https://academic.oup.com/occmed/article-abstract/47/1/25/1414172 by guest on 21 September 2019
after 1990. The Belgian nurses could have been
displaying a similar reporting effect, which may be
related to their work perceptions. It is also possible
that the inter-country differences could be explained
by differences in staffing levels and/or local implemen-
tation of legislation. Although compliance with the
European Directive is doubtless incomplete, it might
be reasoned that the hospitals concerned would have
implemented the principles of reduced manual
handling operations to some (similar) extent. There
was no reason, so far as we could discern, to indicate
that implementation, staffing levels or use of mechanical
aids was substantially different between the countries.
The workloads at the time of the study are probably
a reasonable representation of contemporary expo-
sures, so it was a little surprising that the point
prevalence figure for back pain was no better than
reported some 10 years previously in nurses.26
That the point prevalence of LBT is not dependent
on workload has been noted previously among nurses.26
However, the lower prevalence of a history of LBT with
heavier workloads found here contradicts previous
reports (e.g. Videman et a/."). Because of methodo-
logical differences and definitions of symptoms,
comparisons between occupational prevalence studies
are difficult. It is possible that our measure of workload
was insensitive, but the fact that the 'heavy' group
here had a typical exposure (in hours per week) some-
what higher than the equivalent group in the Videman
et al. study renders this unlikely. Their study compared
nursing aides with qualified nurses (where the aides
had the higher workload and the higher prevalence),
but when their whole sample was combined the rela-
tionship between 'heavy' work and previous back pain
was less clear cut — only for those aged less than 30
years was the relationship statistically significant."
The present study found no significant relationship
between present workload and either work loss in the
previous 12 months, or the belief that work had been
a cause of symptoms in the previous 12 months. It
has been commented that simply reducing loads on
the spine through reductions in manual handling is
unlikely to significantly improve matters when only
manual handling training is implemented.27 Alternative
preventive strategies which involve an ergonomic
approach, proposing job redesign through task analysis

and training, have been proposed27 and have met with
some success,28 yet nurses apparently continue to see
patient handling as a major factor in the development
of back trouble.25
The potential for ergonomics intervention to reduce
the incidence of injury to nurses24 is not in question,
but the epidemiological profile of musculoskeletal
disorders (in all working groups) is confounded with
symptoms that are not directly work-related. What
becomes of the individual after developing a disorder
(whether by work-injury or otherwise), how quickly
they recover or how much absence they take, probably
has more to do with psychosocial than physical
issues.13*29 The results of the present study suggest that
the nurses' reporting of back or musculoskeletal prob-
lems, as well as the subsequent course, is influenced
by psychosocial phenomena. Thus, if the longer-term
effects of back and musculoskeletal disorders in nurses
is to be reduced, some form of psychosocial interven-
tion, before symptoms develop, would appear to be
an appropriate addition to conventional ergonomic
intervention. Indeed, a recent intervention study in
industry has shown that broadcasting a simple
educational pamphlet (stressing positive attitudes and
beliefs) can reduce absenteeism due to low back
trouble.14
In conclusion, the relatively high workload of Dutch
nurses was not associated with an increased occurrence
of back and musculoskeletal complaints, statistically
significant work loss or the perception that work is
harmful. This may be because of a more positive
outlook on their health and job (which could be an
inherent social characteristic or due to some, uniden-
tified, positive and supportive approach by hospitals
in The Netherlands). Whether the relationship between
low prevalence and positive psychometrics is cause or
effect can only be answered by longitudinal studies,
but there is clinical evidence that the psychological
factors associated with chronic back pain may be
present before the onset of trouble.29 The title of this
paper questions the value of ergonomic intervention.
The results presented here suggest that 'minimal nursing'
plans alone, whilst having the potential to reduce injury
rates, will have a sub-optimal influence on symptoma-
tology. This becomes important when considering
either the detrimental effect that musculoskeletal
symptoms have on morale and work loss, or the risk
of chronic sequelae. We believe there is justification
for adopting an additional programme of psychosocial
intervention which challenges misconceptions about
the detrimental effects of work on health, and encour-
ages an element of self-management of symptoms.
ACKNOWLEDGEMENTS
The authors would like to acknowledge the support
of the Belgian Federal Services for scientific, technical
and cultural matters, and the British Council for
assistance with travel costs.
A. K. Burton ef a/.: Back and muscutosketetal problems In nurses 31
REFERENCES
1. Hrudey WH Overdiagnosis and overtxeatment of low back pain:
Long term effects. J Occup Rehab 1991; 1: 303-311.
2. Leamon TB. Research to reality: a critical review of the validity
of various criteria for the prevention of occupationalry induced
low back pain disability. Ergonomics 1994; 37: 1959-1974.
3. Cust G, Pearson JCG, Mair A. The prevalence of low back
pain in nurses. Int Nursing Rev 1972; 19: 169-179.
4. Stubbs D, Buckle P. The epidemiology of back pain in nurses.
MedEdu 1984; 32: 935-938.
5. Ferguson D. Strain injuries in hospital employees. MedJAust
1970; 1: 376-379.
6. Harber P, Billet E, Gutowski M, Soo-Hoo K, Lew M, Roman A.
Occupational low back pain in hospital nurses. J Occup Med
Downloaded from https://academic.oup.com/occmed/article-abstract/47/1/25/1414172 by guest on 21 September 2019
1985; 27: 518-524.
7. Hickman M, Mason V. The Prevalence of Back Pain. A Report
Prepared for the Department of Health. London, UK: Office of
Population Censuses Surveys, 1993.
8. Health Services Advisory Commission. Guidance on Manual
Handling of Loads in the Health Services. Health Services Ad-
visory Commission, 1992.
9. Venning PJ, Walter SD, Stitt LW. Personal and job-related
factors as determinants of incidence of back injuries among
nursing personnel. J Occup Med 1987; 29: 820-825.
10. Stappaerts K Lage rugpijn: een onderzoek bij verplegenden en
richtUjnenvoorpreventie. Lcuven, Belgium: Hermes, Kul, 1989.
11. Videman T, Numinen T, Tola S, Kuorinka I, Vanharranta H,
Troup JDG. Low back pain in nurses and some loading factors
of work. Spine 1984; 9: 400-404.
12. PheasantS. Back pain at work. In: Ergonomics,\fbrk and Health.
London, UK: Macmillan Press, 1991. 3: 57-76.
13. SymondsTL, Burton AK.Tillotson KM, Main CJ. Do attitudes
and beliefs influence work loss due to low back trouble? Occup
Med 1996; 46: 25-32
14. Symonds TL, Burton AK, Tillotson KM, Main CJ. Absence
due to low back trouble can be reduced by psychosocial inter-
vention at the workplace. Spine 1995; 20: 2738-2745.
15. Berg ST, Dahl L, Dehlin O, Hedenrud B. Psychological
perception of nursing aides' work. ScandJ Rehab Med 1976;
8:79-84.
16. Klaber-Moffett JA, Hughes GI, Griffiths P. A longitudinal study
of low back pain in student nurses. IntJ Nursing Studies 1993;
30: 197-212.
17. Waddell G, Newton M, Henderson I, Somerville D, Main CJ.
A fear avoidance belief questionnaire (FABQ) and the role of
fear-avoidance beliefs in chronic low back pain and disability.
Pain 1993; 52: 157-168.
18. Rosenstiel AK, Keefe FJ. The use of coping strategies in chronic
' low back pain patients: relationship to patient characteristics
and current adjustment. Pain 1983; 17: 33-44.
19. Main CJ, Waddell G. A comparison of cognitive measures in
low back pain: statistical structure and clinical validity at initial
assessment. Pain 1991; 46: 287-298.
20. Main CJ, Waddell G. The detection of psychological abnor-
mality in chronic low back pain using four simple scales. Curr
Con Pain 1984; 2: 10-15.
21. Garg A, Owen PD, Carlson B. An ergonomic evaluation of
nursing assistants' job in a nursing home. Ergonomics 1992; 35:
979-995.
22. Caboor D, Claryis JP, Zinzen E, et aL A method to identify the
attitude of 'Supernurses' towards their daily tasks. London,
U K Society for Back Pain Research, 15 October 1993.
23. Stubbs DA, Rivers PM, Hudson MP, et al. Patient handling
and truncal stress in nursing. Proceedings of conference
organised by the Nursing Practice Research Unit Northwick
Park Hospital: Back Pain Association and DHSS, 1980.
24. Pheasant S, Stubbs D. Back pain in nurses: epidemiology and
risk assessment Appl Erg 1992; 23: 226-232.
25. Leighton DJ, Reilly T. Epidemiological aspects of back pain:
the incidence and prevalence of back pain in nurses compared
32 Occup. Med. Vol. 47, 1997
to the general population. Occup Med 1995; 45: 263-267.
26. Stubbs DA, Buckle PW, Hudson MP, Rivers PM, Worringham
CJ. Back pain in the nursing profession. I. Epidemiology and
pilot methodology. Ergonomics 1983; 26: 755-765.
27. Stubbs DA, Buckle P, Hudson M, Rivers P. Back pain in the
nursing profession II: The effectiveness of training. Ergonomics
1983; 26: 767-779.
28. Aird JW, Nyran P, Roberts G, Aghazadeh F, eds. Trends in
Ergonomics/Human Factors V. North-Holland; Elsevicr Science
Publishers BV, 1988.
29. Burton AK, Tillotson KM, Main CJ, Hollis S. Psychosocial
predictors of outcome in acute and subchronic low back trouble.
Spine 1995; 20: 722-728.
Downloaded from https://academic.oup.com/occmed/article-abstract/47/1/25/1414172 by guest on 21 September 2019