https://doi.org/10.15218/ejnm.2018.06 EJNM, Vol. 1, No. (1), May, 2018 Original Article Prevalence and Risk Factors of Work-Related Musculoskeletal Disorders among Nurses in Erbil Teaching Hospitals ABSTRACT INTRODUCTION Work-related musculoskeletal disor- ders (WMSDs) are isolated or shared prob- lems in the muscles, tendons, synovial membranes (joint tissue) nerves, fascia (connective tissue) and ligaments, with or without tissue degeneration. They are diag- nosed by the occurrence of symptoms, along with or not, like: pain, numbness, feeling of heaviness and fatigue *1+. These injuries generally affect the superior limbs, scapular region around the shoulder and cervical region, but can also affect the infe- rior limbs and are frequent causes of tem- porary or permanent occupational disabili- ties. Injury caused by work-related muscu- loskeletal disorders arise from the extreme use of the musculoskeletal system and its inadequate recovery, and comprises clini- cal conditions. Workers are victims when they are submitted to poor work condi- tions *2+. The risk of work-related musculo- skeletal disorders is high among different healthcare professionals *3+. WMSDs hap- pen in some careers, including nursing, Background and objective: The term musculoskeletal disorders includes a gamut of in- flammatory and degenerative conditions that affect the muscles, tendons, ligaments, joints, peripheral nerves, and supporting blood vessels with consequent ache, pain or dis- comfort. The risk of musculoskeletal disorders is high among various healthcare profes- sionals. This study investigated the prevalence of work-related musculoskeletal disorders and risk factors among nurses in Erbil teaching hospitals. Methods: This cross-sectional study was conducted in Erbil city teaching hospitals in the Kurdistan Region of Iraq. A total number of 256 nurses were selected as study samples through the use of non-probability convenience sampling method. The data were collected by a standardized questionnaire through the use of the interview (face to face) technique. Results: The previous 12-month prevalence of work-related musculoskeletal disorders among nurses was 67%. Lower back disorder was the most prevalent disorder compared to other body regions at 75% followed by 52% reported in one or both knees, and the low- est percentages (9%) reported in the upper back region. Conclusion: Work-related musculoskeletal disorders are high among nurses. There was an association between the prevalence of musculoskeletal disorders, genders, and training program on preventing work-related musculoskeletal disorders. It is recommended that training programmes on prevent work-related musculoskeletal disorders be implemented for all nurses. Keywords: Musculoskeletal disorders; Work-related musculoskeletal disorders; Erbil; Low back disorder. Salih Ahmed Abdulla; Department of Nursing, College of Nursing, Hawler Medical University, Erbil, Iraq. (Correspondence: salih.ahmed@nur.hmu.edu.krd) 42 Erbil Journal of Nursing & Midwifery Received: 15/9/2017 Accepted: 14/11/2017 Published: 5/5/2018 https://doi.org/10.15218/ejnm.2018.06 EJNM, Vol. 1, No. (1), May, 2018 Original Article three or four times more often than in the general population *4+.Nurses are at risk of WMSDs due to their employment. Hospital nursing tasks are generally composite and involve many physical activities that can lead to acute and chronic work related musculoskeletal disorders*5+.The main risk factors related to WMSDs among nurses are extended hours of standing in the oper- ation theatre; carrying and transporting patients; awkward posture; working with- out adequate breaks; numerous forward bending for dressing patients, I.V line inser- tions, and giving injections; and carrying heavy weights*4,6+. Demographic charac- teristics and psychosocial factors such as age, gender, physical status, smoking, and workplace stress are also known to be im- portant predictive variables*7+.Decreasing risk factors is an important component of both treatment and prevention. However, the effects of rest time and physical activi- ties on musculoskeletal symptoms and dis- ability in worker populations have showed inconsistent results *8+. This study investigated the prevalence and risk factors of work-related musculoskele- tal disorders (WMSDs) among nurses in Erbil teaching hospitals. The design of the study was quantita- tive cross sectional. It was conducted in the Erbil city teaching hospitals in the Kurdi- stan Region of Iraq. The hospitals included: Hawler teaching hospital, Rizgary teaching hospital, Maternity and Delivery teaching hospital, Raparin paediatric teaching hospi- tal, and the Surgical Specialty teaching hos- pital/Cardiac Centre. All of the nurses of the teaching hospitals who met the inclu- sion and exclusion criteria were the popu- lation of this study. Two hundred and fifty six nurses were selected as samples from different units and wards and from differ- ent work shifts in the five hospitals. Non-probability convenience sampling technique (also called accidental sampling) was used according to the following inclu- sion criteria: nurses who worked on all shifts according to the policy of the hospi- tals, nurses who work on different units and wards, both genders, and all catego- ries of nurses (e.g. nursing school gradu- ate, preparatory nursing graduate, institu- tional graduates and post graduates). Data were collected through interviews by using a standardized questionnaire called the standardized Nordic Questionnaire for Musculoskeletal Symptoms *9+. The data gathered from the nurses at their work places did not affecting on their duties dur- ing the interview time. Each nurse's inter- view took 10-15 minutes. The researcher gave examples when needed but did not assist in answering the questionnaire. The nurses’ agreement for participation in the study was obtained and the interview was carried out individually. The reliability of the Standardized Nordic Questionnaire for Musculoskeletal Symptoms has been con- firmed in various studies. Dawson et al. (2009) reported that the Questionnaire had demonstrated reliability results Kappa values ranging from 0.88 to 1, and this questionnaire has been internationally val- idated. The data were analyzed with Statis- tical Package for Social Sciences (SPSS) ver- sion 21. Frequencies, Chi square test and Fisher exact test were used for interpreta- tion of the data. The probability values greater than 0.05 were considered statisti- cally insignificant throughout the analysis. Figure 1 shows the prevalence of work related musculoskeletal disorders among nurses in Erbil teaching hospitals. The high- est number of nurses who demonstrated WMSDs was 175 (66.8%). Table 1 shows the work-related musculoskeletal disor- ders (WMSDs) experienced per each body METHODS 43 Erbil Journal of Nursing & Midwifery RESULTS https://doi.org/10.15218/ejnm.2018.06 EJNM, Vol. 1, No. (1), May, 2018 Original Article quarter (28.6%) had BMI between 25-29.9 (overweight); and 45% did not do regular physical exercise in comparison to the nurses who had WMSDs were performed regular physical exercise (21.8%). The table also show that there is significant associa- tion between the prevalence of WMSDs among nurses and gender (p-value = 0.05). The results show that there is no signifi- cant relationship between marital status and prevalence of WMSDs. Data analysis also shows that there is no significant asso- ciation between the prevalence of WMSDs among participant nurses and variables of smoking, exercise and BMI (p-value= 0.05). Table 3 shows that 31.7% of the nurses who had WMSDs had between 1-10 years’ experience in nursing, near to one fifth (19.8%) of them work in surgical ward, near to half (49.2%) were not having additional job, and 55.3% were not partici- pated in any training toward preventing WMSDs. The data finding shown in figure (1) identifies that during the last twelve months, the prevalence of work-related musculoskeletal disorders (WMSDs) among nurses in Erbil teaching hospitals in this study was 66.8%. This finding is in line region in the past twelve months. Lower back disorder was reported by three quar- ters (75%) of the study sample, followed by 52% disorders reported in one or both knees. The lowest percentage (9%) of dis- orders was reported in the upper back re- gion. Table 2 shows that 29% of the nurses who had WMSDs were between 30 to 39 years, 40.1% of the female nurses had WMSDs in comparison to male nurses (26.7%). More than half (56.5%) of the study sample who had WMSDs were married in comparison to 10.3% who were single. The highest per- centage (37.4%) of the nurses who had WMSDs had graduated from the Institute of Nursing of the nurses, who had WMSDs 60.3% were non-smoker; more than a 44 Erbil Journal of Nursing & Midwifery Figure 1: Prevalence of the Musculoskele- tal Disorders (MSDs) among nurses Table 1: Prevalence of the WMSDs by the body regions Body regions Yes No Total F (%) F (%) F (%) Neck 80 (46) 95 (54) 175 (100) Shoulders 69 (39) 106 (61) 175 (100) Elbows 22 (13) 153 (87) 175 (100) Wrists/ Hands 63 (36) 112 (64) 175 (100) Upper back 16 (9) 159 (91) 175 (100) Lower back 131 (75) 44 (25) 175 (100) One or both Hips/Thighs 52 (30) 123 (70) 175 (100) One or both Knees 91 (52) 84 (48) 175 (100) One or both Ankles/ Feet 20 (11) 155 (89) 175 (100) DISCUSSION https://doi.org/10.15218/ejnm.2018.06 EJNM, Vol. 1, No. (1), May, 2018 Original Article with the results of a study done in Ethekwini/South Africa, when the re- searchers reported that the twelve months prevalence of WMSDs among the nurses was also 67%,*10+, and also similar to one done in Zambia (68.9%),*11+. However, the current study’s result is higher than those observed in Canada (61%) *12+, and the United States (60%) *13+. The rate was low- er than that in what was reported among nurses in Brazil which was 93%*14+, among Turkish nurses 90%*15+, and among Iranian nurses was 89.9%*16+. The reason behind the different prevalence rate of WMSDs in different countries/hospitals might be the differences in psychological and physical 45 Table 2: Association between socio-demographic characteristics of the nurses and WMSDs Erbil Journal of Nursing & Midwifery Variable WMSDs P-value Yes No Total F (%) F (%) F (%) Age groups 20-29 41 (15.6) 28(10.7) 69 (26.3) 0.13 30-39 76 (29) 34 (13) 110 (42) 40-49 34 (13) 20 (7.6) 54 (20.6) 50-59 24 (9.2) 5 (1.9) 29 (11.1) Gender Male 70 (26.7) 60 (22.9) 130 (49.6) < 0.001 Female 105 (40.1) 27 (10.3) 132 (50.4) Marital Status Single 27 (10.3) 22 (8.4) 49 (18.7) 0.05 Married 148 (56.5) 65 (24.8) 213 (81.3) Educational Level School nursing 13 (5) 1 (0.4) 14 (5.4) 0.23 Preparatory nursing 41(15.6) 18 (6.9) 59 (22.5) Institutional nursing 98 (37.4) 53 (20.2) 151 (57.6) College of nursing 22 (8.4) 14 (5.3) 36 (13.7) Post graduate nursing 1 (0.4) 1 (0.4) 2 (0.8) Smoking Status Yes 17 (6.5) 12 (4.6) 29 (11.1) 0.32 No 158 (60.3) 75 (28.6) 233 (88.9) BMI (Weight Status) <18.5 (Underweight) 52 (19.9) 27 (10.3) 79 (30.2) 0.21 18.5-24.9 (Normal) 43 (16.4) 12 (4.6) 55 (21) 25-29.9 (Overweight) 75 (28.6) 44 (16.8) 119 (45.4) 30-39.9 (Obesity) 5 (1.9) 4 (1.5) 9 (3.4) Physical Exercise Yes 57 (21.8) 29 (11) 86 (32.8) 0.90 No 118 (45) 58 (22.2) 176 (67.2) Total 175 (66.8) 87 (33.2) 262 (100) https://doi.org/10.15218/ejnm.2018.06 EJNM, Vol. 1, No. (1), May, 2018 Original Article environments. Firstly, some hospitals have implemented the policy of “minimal manual lift” and use of devices to change the position of patients which helped to reduce the risk of musculoskeletal disor- ders *17+. Secondly, the difference in the results may be related to socio- demographic characteristics, the range of disease conditions, work characteristics, job factors, practice settings, number of study participants, the availability of basic equipment, and the regular participation of the nurses in strategic training programs programs toward preventing of WMSDs. Many previous studies focused on several body regions due to the tendency of WMSDs affecting more than two body parts. The current study sought to com- pare the prevalence of WMSDs in all nine body regions, identified by the Nordic questionnaire for musculoskeletal symp- toms *9+. The current study revealed that the lower back disorder at 75% was the most prevalent region compared to other body regions followed by one or both knees at 52%, Low back pain was the more prevalent on all units and across all nurse ranks, which was agreed with the several 46 Erbil Journal of Nursing & Midwifery DISCUSSION Table 3: Association between work-related factors with MSDs among nurses Variable WMSDs Yes No Total P-value F (%) F (%) F (%) Years of Experience 1 -10 83 (31.7) 45 (17.2) 128 (48.9) 0.02 11-20 43 (16.4) 31 (11.8) 74 (28.2) 21-30 36 (13.7) 11 (4.2) 47 (17.9) 31-40 10 (3.8) 0 (0) 10 (3.8) 41-50 3 (1.1) 0 (0) 3 (1.1) Unit/ Ward Catheterization 3 (1.1) 2 (0.8) 5 (1.9) 0.7 Consultation 12 (4.6) 8 (3.1) 20 (7.6) Delivery unit 11 (4.2) 2 (0.8) 13 (5) Emergency 16 (6.1) 7 (2.7) 23 (8.8) ICU 29 (11.1) 15 (5.7) 44 (16.8) Medical 24 (9.2) 7 (2.7) 31 (11.8) NICU 6 (2.3) 3 (1.1) 9 (3.4) Surgical 52 (19.8) 27 (10.3) 79 (30.2) Theatre 22 (8.4) 16 (6.1) 38 (14.5) Dual Employment Yes 46 (17.6) 42 (16) 88 (33.6) < 0.001 No 129 (49.2) 45 (17.2) 174 (66.4) Participation in training Yes 30 (11.5) 25 (9.5) 55 (21) 0.03 No 145 (55.3) 62 (23.7) 207 (79) Total 175 (66.8) 87 (33.2) 262 (100) https://doi.org/10.15218/ejnm.2018.06 EJNM, Vol. 1, No. (1), May, 2018 Original Article prevalence of WMSDs and training. The authors reported no conflicts of interest. *1+ National Institute for Occupational Safety and Health. Musculoskeletal disorders and workplace factors: a critical review of epidemiologic evidence for work- related musculoskeletal disorders of the neck, upper extremity, and low back. Cincinnati (OH). (DHHS (NIOSH) Publication No.(97B141) 1997 *2+ Ministry of Health, Repetitive Strain Injury (RSI), Work -Related Musculoskeletal Disorders (MSDs), Pain re- lated to work. Protocols of comprehensive health care of different complexity worker, Brasilia: Ministry of Health, 2006. *3+ Harcombe H, Herbison GP, McBride D, Derrett S. Mus- culoskeletal disorders among nurses compared with two other occupational groups. Occup Med; 2014, 64: 601–7. *4+ Punnett L, Wegman DH. Work-related musculoskele- tal disorders: the epidemiologic evidence and the debate. J ElectromyogrKinesiol,2004, 14:13-23. *5+ Ando S, Ono Y, Shimaoka M, Hiruta S, Hattovi Y, Hori F, et al. 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Standardised Nordic questionnaires for the analysis of musculoskel- etal symptoms,ApplErgon, 1987, 18 (3): 233-7. *10+ BabusisiweThandi Evan Kumalo, The relationship between work-related musculoskeletal disorders, absenteeism and visits to the staff clinic by nurses in an Ethekwini district hospital, Durban University of Technology,2014,Available:http://ir.dut.ac.za/ handle/10321/1255?show=full. *11+ Loveness A. Nkhata1, Tonya M. Esterhuizen1, Seter Siziya, Peter D. C. Phiri, Esther Munalula-Nkandu, Hastings Shula. The Prevalence and Perceived Con- tributing Factors for Work-Related Musculoskeletal Disorders among Nurses at the University Teaching Hospital in Lusaka, Zambia. sjph, 2015, 3(4): 508-513. Available: http://www.sciencepublishinggroup.com/ journal/paperinfo.aspx?journalid previous studies. In addition, low back pain was the most prevalent body region in most of the previous studies. *18+. The pre- sent study shows that the most nurses with WMSDs were those in their third decade of age, and there was no significant associa- tion between age categories and preva- lence of WMSDs (p-value = 0.130). The cur- rent study is in agreement with the findings of *19+, that there is no significant relation- ship between age and prevalence of WMSDs within this population at (p-value 0.05) and it is also agreed with the reports of a study done among nurses in Zambia *20+. The current study shows that 55.3% of the nurses who had WMSDs were not participated in any training toward pre- venting injuries in comparison to only 11.5% of the nurses who also had WMSDs but they were participated in training pro- grams. This finding indicates that participa- tion in training programs toward pre- venting WMSDs by nurses may be a factor to decrease WMSDs.The table also shows that there is a significant relationship be- tween the prevalence of WMSDs among participant nurses and their participation in training toward prevent WMSDs at (p- value = 0.03). The twelve months time period of WMSDs in this study was 67%. Lower back disorder Demographic factors such as age, marital status, educational level, body mass index, smoking, and physical exercise perfor- mance did not predispose to an increase in the prevalence of WMSDs. But some de- mographic factors such as gender were found have a strong relationship with the prevalence of WMSDs.The prevalence of WMSDs is higher among nurses who were not participated in any training strategies to prevent work-related musculoskeletal disorders (70%), and it found that there was a strong relationship between 47 Erbil Journal of Nursing & Midwifery CONCLUSION CONFLICTS OF INTEREST REFERENCES https://doi.org/10.15218/ejnm.2018.06 EJNM, Vol. 1, No. (1), May, 2018 Original Article *12+ Yassi A, Gilbert M, Cvitkovich Y. Trends in injuries, illnesses, and policies in Canadian healthcare work- places, Can J Public Health, 2005, 96:333–9. Availa- ble:http://www.ncbi.nlm.nih.gov/ pubmed/16238148. *13+ Trinkoff, A. M., Lipscomb, J. A., Geiger-Brown, J., & Brady, B. 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Available: http:// www.sciencepublishinggroup.com/journal/ paperinfo.aspx?journalid=. 48 Erbil Journal of Nursing & Midwifery