Elsevier

Applied Ergonomics

Volume 45, Issue 6, November 2014, Pages 1634-1640
Applied Ergonomics

Developing a comprehensive approach to risk management of musculoskeletal disorders in non-nursing health care sector employees

https://doi.org/10.1016/j.apergo.2014.05.016Get rights and content

Highlights

  • High prevalence of discomfort levels are evident in the health care sector.

  • WMSD risk in the health care is predicted by physical and psychosocial hazards.

  • Risk management of WMSDs must address physical and psychosocial hazards.

  • A toolkit approach is proposed to improve risk management of WMSDs in health care.

Abstract

This study of selected jobs in the health care sector explored a range of physical and psychosocial factors to identify those that most strongly predicted work-related musculoskeletal disorders (WMSD) risk. A self-report survey was used to collect data on physical and psychosocial risk factors from employees in three health care organisations in Victoria, Australia. Multivariate analyses demonstrated the importance of both psychosocial and physical hazards in predicting WMSD risk and provides evidence for risk management of WMSDs to incorporate a more comprehensive and integrated approach. Use of a risk management toolkit is recommended to address WMSD risk in the workplace.

Introduction

The aetiology of work-related musculoskeletal disorders (WMSDs) is now known to be very complex, with risk influenced by varying combinations of a diverse range of psychosocial hazards in addition to the more widely recognized hazards associated with physically demanding work (Côté et al., 2009, Eatough et al., 2012, Marras et al., 2009, National Research Council, 2001). Despite extensive evidence of the importance of psychosocial hazards, workplace interventions intended to reduce WMSD risk continue to focus primarily on controlling physical hazards arising from the performance of particular manual handling tasks. In fact, research evaluating various WMSD risk management interventions shows that the most effective interventions are those that take a multidisciplinary approach and address “organisational”, “technical” and “personal/individual” issues (European Agency for Safety and Health at Work, 2008, Fray and Hignett, 2013, Hignett, 2003).

Health care work has been identified as high risk for developing WMSDs (Tuller et al., 2010). Australian data on work-related injuries (which include WMSDs) show that the health and community services sector has one of the highest claims rates (Safe Work Australia, 2013). Most attention has been directed towards nursing— as the largest occupational group in the health care sector— in terms of mitigation of risks associated with WMSDs. However, the health care sector employs a large range of occupations, including paramedics, care assistants, theatre support staff, maintenance, food services, and cleaning staff (Hignett, Fray, et al., 2007) all of which require further attention to reduce risks associated with WMSDs. These occupational groups—clinical and non-clinical—play a key role in the delivery of high quality health care and a systematic approach to reducing WMSD risk should be seen as integral in attempts towards improved patient care. As such, the focus of the current study is directed towards non-nursing occupational groups. More specifically the current study aims to identify key predictors of WMSD risk in these occupational groups, and these findings will support the development of a risk management toolkit.

People employed in the healthcare sector occupy a wide range of jobs, including both clinical and non-clinical roles, and undertake a range of physically demanding tasks that have been linked to the development of WMSDs (Aasa et al., 2005, Fray and Hignett, 2013, Long et al., 2012). These employees also work in complex and demanding environments and are faced with a range of non-physical hazards or psychosocial factors that are typically less well identified and managed than physical hazards (NIOSH., 2009, Schoenfisch and Lipscomb, 2009). A systematic approach to addressing issues in the health care sector is needed given the complexity of system (Carayon, 2012, Hignett et al., 2013). Whilst new roles emerge for ergonomics and human factors practitioners, further work is required to improve management of existing issues such as WMSDs, particularly in the occupational groups who have not been extensively explored.

Traditionally, WMSD risk management in health care has focussed on reducing exposure of nurses to physical hazards involving handling of patients, through programs such as “No Lift” (Engkvist, 2006). Significant reductions in WMSD claims have been reported in some instances following the introduction of No Lift (Department of Human Services, 2002). Holterman et al. (2013) reported on links between physical hazards and subsequent low back pain in health care workers employed in the aged care sector. However, much less focus has been given to non-clinical areas such as food services, patient transfer, and cleaning, which also expose staff to range of hazardous activities and associated risks (Simon et al., 2008). Restructuring and budget cuts in the health sector mean that fewer staff are available to complete necessary work (Westgaard and Winkel, 2011).

Paramedics have been participants in some studies (Aasa et al., 2005, Hignett et al., 2007a, Studneck and Mac Crawford, 2007) and were included in the study reported here. Focus on musculoskeletal disorders has generally centered on physical aspects of the role, such as patient lifting and moving equipment and patients. However, Aasa et al. (2005) examined the role of physical and psychosocial factors in paramedics and found links between level of psychological demands and neck-shoulder complaints. Hignett et al., 2007a, Hignett et al., 2007b also analysed management of musculoskeletal disorders in two ambulance services, but this study was focused on post-injury management rather than prevention strategies, which were the focus of the current study.

A small number of studies targeting employees in non-clinical areas have reported psychosocial hazards as an important factor in the development of WMSDs (Unge et al., 2007, Waters et al., 2006). Michie et al. (2004) undertook an intervention aimed at improving the autonomy and the level of support provided to hospital cleaning staff in order to reduce absenteeism, and reported a small short-term reduction in sickness absence. Carrivick et al. (2005) used a participative approach to reduce risk and severity of injuries from manual handling activities in hospital cleaners. Whilst they found a significant reduction in injuries, their focus was principally on reduction of risks associated with physical not psychosocial factors.

Jobs within the health care sector vary widely and are likely to demonstrate different hazard profiles in relation to WMSDs. Thus, it is important to understand what each job entails and address the hazards relevant to that job to maximise effectiveness of risk reduction strategies. Development of a risk management tool that can be used by a range of occupational groups is the basis for the current study. The survey tool that forms the basis for the toolkit is described and implemented in the health care sector.

Fig. 1 depicts the conceptual framework of the current study. It was developed from an extensive literature review (Macdonald and Evans, 2006), builds on previous models (e.g. Carayon et al., 1999, Kuorinka and Forcier, 1995, National Research Council, 2001) and has been used to design and validate the survey employed in the present study (Macdonald, Evans and Armstrong, 2007).

The physical demands of task performance are usually the most obvious work-related cause of MSDs. Hazards of this type are task-specific, stemming from the postures adopted (static and dynamic) and forces exerted during task performance, which in turn are influenced by the design of workstations and tools, characteristics of objects handled, such as their weight, size and shape, and more general characteristics of the task itself.

WMSD risk is influenced by how work is organised and how tasks are combined to create whole jobs. Work organisational hazards may include high workload, high work rates, inadequate personal control or autonomy, role conflicts, lack of variety, social isolation, inadequate rest breaks, excessively long working hours, night shifts, and so on. Many of these factors can increase exposures to external loads and related physical hazards as well as increasing the likelihood of workers experiencing chronic fatigue and/or prolonged stress. Occupational groups such as paramedics have extended working hours and night work and so are highly exposed to this groups of hazards (Aasa et al., 2005).

The term ‘psychosocial hazard’ is often used to include the organizational factors described above, particularly in relation to risk of psychological injuries and mental health problems. However, for WMSD risk management it is useful to distinguish effects of work organization and job design from effects of work's social context, including the attitudes and behaviours of managers, supervisors and co-workers. Psychosocial hazards have been categorized in a variety of ways based on different theoretical frameworks (Leka et al., 2011). According to the European Framework for Psychosocial Risk Management (European Agency for Safety & Health at Work, 2008), psychosocial hazards include factors related to: job content, workload and workplace, work schedule, control, organisational culture and function, interpersonal relationships at work, role in the organisation, career development, and home–work interface.

The importance of psychological stress and its physiological and behavioural correlates in WMSD aetiology is now widely acknowledged. The individual's ‘stress response’ is multidimensional, including a complex physiological dimension along with behavioural, cognitive and affective dimensions (Cox, 1978). Consistent with this finding, a 1995 model of work-related determinants of WMSD risk included a ‘patho-physiology’ component which included “distress with hormonal, endocrine and immune system response” (Kuorinka and Forcier, 1995), and more recent research has confirmed the critical impact of stress in WMSD aetiology (Marras, 2008).

Stress is sometimes presented as a psychosocial hazard affecting the risk of various occupational health problems including MSDs. However, at the workplace level where a key goal is to identify and control risk from work-related hazards, it is arguably more useful to view stress as a product of such hazards, which, in combination with individual factors, partially mediates the effects of workplace hazards on WMSD risk (Eatough et al., 2012), as indicated by a dotted line in Fig. 1. Job satisfaction, which has been shown to mitigate WMSD risk (Schoenfisch and Lipscomb, 2009) may play a similar mediating role.

The model includes individual factors, which evidence suggests are significantly related to WMSD risk (Widanarko et al., 2011). Widanarko et al. studied the prevalence of WMSDs in a New Zealand sample by age, gender, body region and occupational group; they reported that prevalence of MSDs was related to occupational group and men working in health and community sectors reported more symptoms than women. Organisations cannot normally select employees on the basis of their age or gender, but they can ensure that work required of people in a particular job is matched to their capacities and skill levels, thus reducing WMSD risk.

WMSDs include many different clinical diagnoses, but the reliability of such diagnoses is poor. In a workplace context the specific diagnosis of a WMSD has few if any practical implications for preventative risk management (Wells, 2009). A recent consensus statement by the International Commission on Occupational Health Scientific Committee on Musculoskeletal Disorders concluded that the goal of workplace risk management should simply be to prevent or reduce musculoskeletal discomfort that is at risk of worsening with work activities, and affects work ability or quality of life (Hagberg et al., 2012). That is, regardless of clinical diagnosis, the focus of workplace WMSD risk management should be on reducing levels of musculoskeletal discomfort and pain.

The conventional approach to OHS risk management has been to focus on hazard management – identifying hazards, assessing risk from each identified hazard, and taking any necessary steps to control risk from each hazard separately (Macdonald, 2012b). In addition, focus has primarily been on the reduction of physical hazards rather than on addressing psychosocial hazards. The current study seeks to identify key physical and psychosocial hazards in relation to WMSD risk in the health care sector. These results will then be used to provide support for the development of a more comprehensive approach to risk management of WMSDs.

Section snippets

Participants and procedure

Two large hospital networks (Organisations 1 and 2) and one ambulance service (Organisation 3) in Melbourne, Australia participated in this study. The occupational groups involved in the study were selected in consultation with senior Occupational Health and Safety (OHS) personnel in each organisation, based on their relatively high levels of WMSDs relative to other groups. Occupational groups included in the study were Patient services assistants (PSA), Food services (FS), allied health (AH),

Results

A hierarchical 5 step multiple regression was performed with discomfort score as the dependent variable. Organisation and job categories were entered as dummy variables, with age, gender, physical work, WOAQ, job satisfaction and work-life balance as independent variables. Table 2, which includes standardized regression coefficients, (?), R, R2,, Adj R2, Δ R2, and F score, shows the results of this analysis.

Age and gender were entered in the first step, followed by dummy variables for the

Discussion

A central aim of this study was to examine key predictors of WMSD risk in health care sector employees. Employees who were older, women, and experienced high levels of physical and psychosocial hazards reported higher levels of discomfort than their counterparts. In addition, those with low levels of job satisfaction and poor work life balance were more likely to report relatively high levels of discomfort. The relationship between high discomfort and both low job satisfaction and poor

Conclusions

This study found that both physical and psychosocial hazards contribute independently to WMSD risk levels. Therefore, effective risk management of WMSDs must incorporate both types of hazards if it is to successfully reduce overall prevalence of this type of disorder. To achieve this aim a new approach to risk management is proposed – a toolkit that assist organisation to identify and address the most relevant WMSD risks.

In addition, the degree to which WMSD risk management needs to be

Acknowledgements

This research is supported in part by funding of a Development Grant from WorkSafe Victoria and the Transport Accident Commission (TAC), through the Institute for Safety, Compensation and Recovery Research (ISCRR).

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