NURSING AND HEALTH CARE MANAGEMENT AND POLICY

New low back pain in nurses: work activities, work stress and sedentary lifestyle
Vera Yin Bing Yip
PhD MPH GDipEd BAAppSc RN

Assistant Professor, School of Nursing, Faculty of Health and Social Sciences, The Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong, China

Submitted for publication 11 September 2002 Accepted for publication 23 October 2003

Correspondence: Vera Y.B. Yip, School of Nursing, Faculty of Health and Social Sciences, The Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong SAR, China. E-mail: hsvyip@inet.polyu.edu.hk

YIP Y.B. (2004)

Journal of Advanced Nursing 46(4), 430440 New low back pain in nurses: work activities, work stress and sedentary lifestyle Background. Low back pain is common among nurses. Previous studies have shown that the risk of low back pain increases rapidly with greater amounts of physical work and psychological stress, but is inversely related to leisure activities. However, these previous studies were predominantly retrospective in design and not many took account of three factors simultaneously. Aims. This 12-month prospective study examined the relationships between work activities, work stress, sedentary lifestyle and new low back pain. Methods. A total of 144 nurses from six Hong Kong district hospitals completed a face-to-face baseline interview, which was followed-up by a telephone interview. The main study measures were demographic characteristics, work activities, work stress, physical leisure activities and the nature of new low back pain during the 12-month follow-up period. Level of work stress, quality of relationships at work, level of enjoyment experienced at work, and work satisfaction were self-reported. Results. Fifty-six (389%) nurses reported experiencing new low back pain. Sedentary leisure time activity was not associated with new low back pain. Being comparatively new on a ward (adjusted relative risk 290), working in bending postures (adjusted relative risk 276) and poor work relationships with colleagues (adjusted relative risk 252) were independent predictors of new low back pain. Conclusion. The ndings of this study suggest that low back pain is a common problem in the population of nurses in Hong Kong. Being comparatively new on a ward, bending frequently during work and having poor work relationships with colleagues are independent predictors of new low back pain. Training for high-risk work activities and ergonomic assessment of awkward work postures are essential. Moreover, relaxation and team-building workshops for nurses, especially those who are less experienced in the type of work on their current ward, are recommended. Keywords: low back pain, nurses, patient ambulation, moving and handling, work relationships

Introduction
This paper is based on a study of back pain in nurses (Yip 2001) and focuses on those who, in a baseline interview, did not report experience of low back pain (LBP). These nurses
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were interviewed by telephone about the presence of LBP during a 12-month follow-up period. Understanding the effects of work and lifestyle is an important rst step in designing nurse-specic interventions to facilitate management and prevention of LBP.
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Work and lifestyle factors for new LBP in nurses

Background
Low back pain is common among nurses. Back injury accounts for a large number of reported disabilities in nurses, who have one of the highest levels of back injury in all occupational groups (Jensen 1987). Malone (2000) states that ergonomic risk factors for musculoskeletal injuries include force, repetition, awkward posture and static posture. Awkward posture can increase exion of the spine, induce disc rupture and produce changes similar to those seen in natural disc degeneration. Common activities in nursing work, such as heavy manual transferring, frequent twisting and bending, have been identied as important physical risk factors for LBP (Smedley et al. 1997). The occurrence of LBP can partly be explained by work activities involving joint loading and awkward posture (Walsh et al. 1991). Psychological stress at work has been reported as a common factor in LBP among nurses (Hazard et al. 1996, Fishbain et al. 1997). Although the exact mechanism that links high work stress to LBP is not denitively known, stress may increase muscle tension or amplify painful sensations such as LBP. Linton (2001) reviewed 21 studies and identied ve other psychological work risk factors that predict LBP. These were poor job satisfaction (Bergenuud & Nilsson 1988, Biering-Sorensen et al. 1989, Bigos et al. 1991, Ready et al. 1993, Papageorgious et al. 1997, Van der Weide et al. 1999); monotonous work (Rossingol et al. 1993); poor relationships at work (Bigos et al. 1991, Leino & Hanninen 1995, Magnusson et al. 1996, Van der Weide et al. 1999); perceived demands/load (Van der Weide et al. 1999); and perceived ability to work (Hazard et al. 1996, Fishbain et al. 1997). Moreover, an association between low mood and future risk of LBP has also been recognized (Smedley et al. 1997). Previous studies report that physical leisure activities may enhance psychological well-being and generally improve mood (Hassme n et al. 2000), and may reduce anxiety (Cameron & Hudson 1986) and anger (Buchman et al. 1991). It has been suggested that 30 cumulative minutes or more of moderately intense physical activity on most days of the week may prevent LBP by enhancing the end-plate permeability of vertebral discs (i.e. improving the end-plate blood supply, which may eliminate accumulated irritating tissue uids and inammation) (Battie et al. 1989, Hildebrandt et al. 2000). In addition, physical exercise in leisure time can enhance spinal mobility by stretching and relaxing musculature (Leino 1993). Some studies reveal an association vaara between a low level of leisure activities and LBP (HeliO 1980, Harreby et al. 1997). After reviewing four prospective studies and 34 retrospective studies, Hildebrandt and his

team concluded that most studies on leisure activities did not show any association with LBP (Hildebrandt et al. 2000). The evidence is not consistent across different studies and study designs. Although studies show that risk of LBP increases rapidly with greater amounts of physical work and psychological stress, they have some limitations. For instance, they are predominantly retrospective in design and not many target populations of Asian nurses. It is often not made clear whether observed associations between physical work and psychological stress took account of both factors simultaneously.

The study
Aim
The aim of this study was to investigate relationships between physical work activities, work stress, physical inactivity in leisure time, and the occurrence of new LBP in Hong Kong nurses. The research questions were whether: physical work activities are associated with new LBP; work-related psychological stress is associated with new LBP; and a low level of physical leisure activity is associated with new LBP.

Design
A 12-month prospective study design was used.

Participants
Participants were drawn from six Hong Kong district hospitals using convenience sampling. Enrolled and registered nurses who had worked in a hospital setting, in the same job or unit, full-time for at least one month were eligible to participate. Those who had experienced LBP in the 12 months previous to the baseline study (Yip 2001) were excluded. Twelve months after a baseline interview and physical measurements, participants were questioned by telephone about the occurrence of LBP during the intervening period. Of the 224 nurses who participated in the baseline interview, 144 (643%) took part in the telephone interview. At this follow-up, 13 (54%) were excluded because they had developed a prolapsed intervertebral disc, and 67 (299%) did not participate for other reasons. Of these, contact was lost with 746% (six contact attempts were made by telephone and a reminder letter sent), 239% did not want to continue
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any further, and 15% were away from home. The distribution of data on gender, marital status, age, LBP status, current post, nursing experience, working experience and types of ward was similar among the study participants and those who dropped out at follow-up.

Data collection
Initial screening At the baseline interview, participants received initial face-toface screening at the local hospital. This covered sociodemographic factors, nursing experience, work stress, physical activity both in work and leisure time, and any occurrence of LBP. A panel of 10 musculoskeletal experts were invited to verify the content validity of the instrument. Validity was calculated using a content validity index (CVI) (Waltz & Bausell 1981). The overall CVI was 81%, 2 week testretest reliability was 094, and inter-rater reliability was 090. Data collection was by structured interview lasting approximately half an hour. Dening lower back pain LBP was dened as discomfort in the spinal area (between the lower costal margins and gluteal folds), with or without radiation into the leg to below the knee for at least one day during the past 12 months (Lau et al. 1995). The study focussed on examining non-specic LBP, as more than 90% of cases have no specic anatomical aetiology, and, therefore, pain caused by previous back surgery, cancer, vascular disease or menstruation alone was excluded (Nuwayhid et al. 1993). Moreover, pregnant nurses and those who had had cancer, scoliosis, prolapsed intervertebral disc, spine deformities, ankylosing spondylitis and leg length discrepancy were also excluded. At the end of the study, participants were divided into two groups: those with new LBP and those without. The new LBP group consisted of participants who had developed LBP during the 12-month follow-up period. The description of current LBP was adapted from Aberdeens LBP Scale (Ruta et al. 1994). The non-LBP pain group comprised those who had not experienced LBP at either the baseline interview or during the follow-up period. Independent variables Sociodemographic information included age, sex, number of children and marital status. Participants experience in nursing was also noted, and questions about work activities, work-related stress and sedentary lifestyle were included. Details on work activity focused on the handling of materials
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and patients, and self-reported posture over an average shift in the past 12 months. Material handling included lifting, moving, carrying, and holding loads (Hoogendoorn et al. 1999). Patient handling included the lifting and moving of patients (Hoogendoorn et al. 1999). The details of material and patient handling activities were based on a denition used by Harber et al. (1985) in their investigations in the United States of America (USA). Material and patient handling activities were assessed by a self-reported estimation of the number of times that the participant performed each specied direct and non-direct patient care handling task per average shift in the past 12 months. In addition, self-reports of adverse work postures were recorded, including the number of hours spent in prolonged standing, walking, bending, twisting, having hands above shoulder level and sitting in each shift. Questions on psychological stress relating to work covered relationships with colleagues, relationships with managers or supervisors, overall work satisfaction (always/often satised vs. occasionally/never satised), being under stress (always/ often under stress vs. occasionally/never under stress) and enjoyment of their work (always/frequently enjoy vs. occasionally/never enjoy) (Bigos et al. 1991). Participants were asked to complete the short 12-item version of the General Health Questionnaire (GHQ) (Goldberg & Williams 1988). The GHQ monitors peoples gross psychological well-being and detects any variations in stress or emotional distress. Participants were also asked to indicate how often (never, occasionally or frequently) they experienced headaches, period pain, constant tiredness, low mood and feelings of tension or of being under stress (Smedley et al. 1995). Leisure-time physical activity level was divided into three categories: sedentary, dened as no sports, exercise or activities that caused breathlessness/sweating in the past week; underactive, dened as three or more sessions per week, lasting at least 20 minutes per session, of any physical activity (including walking, gardening or practising Tai Chi) that resulted in at least some sweating or increase in breathlessness; and active, dened as either three or more sessions per week, for at least 20 minutes per session, of jogging/running, hiking, biking or swimming, resulting in a medium to large sweat or increase in breathlessness, or ve or more sessions per week, for at least 30 minutes per session, of any physical activity that resulted in at least some sweating or increased breathlessness. This denition of active is commensurate with the physical activity recommendations of the Centers for Disease Control and Prevention and the American College of Sports

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Work and lifestyle factors for new LBP in nurses Table 1 Sociodemographic characteristics and nursing experience of nurses with and without new low back pain Nurses with new Nurses without low back pain low back pain (n 56) (n 88) P value

Medicine (Pate et al. 1995). These three physical activity categories were used in light of previous evidence suggesting that they may have differential determinants (Young et al. 1995, King et al. 2000).

Physical factors in the workplace

Data analysis
Power calculation was based on the assumption that 33% of nurses with new LBP frequently bend to lift an item from oor level. According to the power equation calculation (Kelsey et al. 1986, pp. 273278), the power of the study is 66% for 144 recruited nurses. Descriptive statistics were produced, to describe the general characteristics of the nurses and their new LBP. Continuous variables, which included parameters reecting work activities and adverse work posture, were divided into tertiles. The use of tertiles was to maintain consistency and allow comparison with previous data (Yip 2001). Relationships between new LBP and work factors and sedentary lifestyle risk factors were evaluated with chisquare and independent t-tests. Crude relative risk relating to psychological and physical risk factors in the workplace and sedentary lifestyle, and 95% condence intervals were assessed. Backward stepwise multivariate logistic regression was used to estimate the effects of all three study factors, while controlling for other covariates found to be signicant in the univariate analyses. All work activities, stress and lifestyle variables that had a probability value of P < 01 in the univariate analyses were included in the initial backward stepwise multivariate logistic regression. The backward stepwise multivariate selection procedure was based on P-value for entry and removal was 005 and 010. The statistical signicance of the interaction terms was set at P 005. Interactions (two-way only) with patient handling activities and work stress were determined from cross-product terms. All data were analysed using the Statistical Package for the Social Sciences (SPSS), version 9.

(a) Characteristic Age (years), mean (SEM) 3070 (105) Gender Female 48 (857) Male 8 (143) Marital status Single 30 (545) Married 25 (454) Widowed 0 (00) (b) Nursing experience and Current post Enrolled nurses Registered nurses Nursing ofcers Currently working in Medical ward Surgical ward Nursing experience 15 years 610 years > 10 years Current ward experience < 1 year 12 year(s) >2 years prole 6 (107) 45 (804) 5 (89) 42 (750) 14 (250) 33 (589) 8 (143) 15 (268) 22 (393) 20 (357) 14 (250)

3136 (074) 75 (852) 13 (148) 47 (534) 40 (454) 1 (11)

060 094

086

13 (148) 61 (693) 14 (159) 55 (625) 33 (375) 39 (443) 26 (295) 23 (261) 20 (227) 30 (341) 38 (432)

032

015

009

004*

Values are represented as n (%). For continuous data, P-value is calculated by independent t-test; For categorical data, P-value is calculated by chi-square test; *P 005. SEM, standard error of mean.

similar. Employment proles of nurses who had and had not experienced new LBP were also similar, except that the incidence of LBP was signicantly more common in nurses who had worked on their current ward for less than 1 year (P 004) (see Table 1).

Incidence and description of LBP

Results
Sociodemographic characteristics
The majority of participants were women (855%). The mean age of participants was 3110 years old [95% condence interval (CI) of mean 29913229 years old]. Among the 144 participants, 465% were married and lived with their spouse, the remainder were not living with their spouse, widowed, divorced, separated or single. The sociodemographic characteristics of new LBP and no LBP groups were

Fifty-six participants experienced new LBP during the 12-month follow-up period, and 88 did not experience LBP either at baseline or during the follow-up period. Therefore, the 12-month incidence of LBP was 39%. Among the new LBP group, 52 (929%) had experienced 113 days of LBP, and four (71%) had experienced 14 days or more. The majority (536%) of those with LBP had experienced more than ve episodes; 816% described the pain as being dull and 143% described it as being tight/stiff type of pain. In self-rating their current LBP, 534% of participants scored the
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pain as 5 or above out of a score of 10, where 10 represents intolerable pain and 1 denotes minimal pain.

Physical work activities and LBP incidence

Table 2 presents associations between new LBP in the past 12 months and 10 direct patient care activities, and Table 3 shows associations between LBP and six work postures

commonly adopted by nurses in a typical shift. The incidence of symptoms of new LBP increased with longer hours spent in one work posture and greater frequency of common work activities, e.g. bending to lift an item from oor level (P 001) and ambulating patients (P 005) (Tables 2 and 3). Conversely, there was no signicant difference in the incidence of LBP that related to other patient or material handling activities and work postures.
Table 2 Association of new low back pain with work activities

Physical factors in the workplace: work activities

Nurses with new low back pain, n 56 (%)

Nurses without low back pain, n 88 (%)

P value (v2)

(a) Patient handling activities (number of times per shift) Transfer patient onto a trolley Lowest tertile 19 (339) Middle tertile 20 (357) Highest tertile 17 (304) Transfer patient between bed and chair Lowest tertile 17 (304) Middle tertile 22 (393) Highest tertile 17 (304) Position patient on bed Lowest tertile 19 (339) Middle tertile 22 (393) Highest tertile 15 (268) Assist patient on/off toilet Lowest tertile 18 (321) Middle tertile 18 (321) Highest tertile 20 (357) Assist patient in or out of the bath Lowest and middle tertile 49 (875) Highest tertile 7 (125) Assist patient while ambulating Lowest tertile 15 (268) Middle tertile 28 (500) Highest tertile 13 (232) (b) Material handling activities (number of times per shift) Move instrument/furniture Lowest tertile 19 (339) Middle tertile 15 (268) Highest tertile 22 (393) Move bed Lowest tertile 14 (250) Middle tertile 23 (411) Highest tertile 19 (339) Carry a piece of equipment weighing 5 lb Lowest tertile 20 (357) Middle tertile 15 (268) Highest tertile 21 (375) Carry a piece of equipment weighing 30 lb Lowest tertile 22 (393) Middle tertile 17 (304) Highest tertile 17 (304) For categorical data, P-value is calculated by chi-square test. *P 005. 434

37 (420) 27 (307) 24 (273) 35 (398) 31 (352) 22 (250) 31 (352) 38 (432) 19 (216) 35 (398) 30 (341) 23 (261) 80 (909) 8 (91) 38 (437) 27 (310) 22 (253)

062

051

077

044

051

005*

30 (341) 24 (273) 34 (386) 37 (420) 29 (330) 22 (250) 40 (455) 24 (273) 24 (273) 32 (364) 31 (352) 25 (284)

010

011

038

083

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Nursing and health care management and policy Table 3 Association of new low back pain with adverse work posture

Work and lifestyle factors for new LBP in nurses

Physical factors in the workplace: work posture Number of hours spent per shift Bend to lift item from oor level Lowest tertile Middle tertile Highest tertile Twisting position Lowest tertile Middle tertile Highest tertile Hands raised above shoulder level Lowest tertile Middle tertile Highest tertile Standing Less than 2 hours At least 4 hours Sitting Less than 2 hours At least 2 hours Walking 4 hours At least 4 hours

Nurses with new low back pain n 56 (%)

Nurses without low back pain n 88 (%)

P value (v2)

16 (286) 12 (214) 28 (500) 17 (304) 12 (214) 27 (482) 19 (339) 10 (179) 27 (482) 21 (375) 35 (625) 39 (696) 17 (304) 36 (642) 20 (357)

30 (341) 35 (398) 23 (261) 39 (443) 16 (182) 33 (375) 32 (364) 19 (216) 37 (420) 23 (261) 65 (739) 54 (614) 34 (386) 66 (750) 22 (250)

001**

024

075

019

047

037

For categorical data, P-value is calculated by chi-square test. **P 001.

Psychological work factors associated with LBP incidence

Participants who reported that they had experienced occasional headaches during the 12 month follow-up had only a slightly higher incidence of new LBP when compared with those who seldom experienced headache (P 006) (Table 4). Nurses who expressed less satisfaction with their relationships with colleagues had a slightly higher incidence of LBP when compared with those who expressed more satisfaction with this aspect, but this difference was not statistically signicant (P 009). There was no signicant association between other factors related to psychological stress at work and the risk of new LBP. Moreover, those who, according to the short 12-item version of the GHQ, experienced more psychological disturbance showed no difference in reported LBP.

Table 5 shows the multivariate model and includes three study factors associated with a risk of new LBP: working in their current ward for less than 1 year (adjusted relative risk 290, 95% CI 112783), longer hours spent in bending per shift (adjusted relative risk 276, 95% CI 106722) and poor work relationships with colleagues (adjusted relative risk 252, 95% CI 103568) were independent predictors of new LBP. The adjusted relative risk for the three independent predictors ranged from 252 to 290.

Discussion
Incidence and characteristics of new LBP
The annual incidence of LBP among nurses in my study was 39%, which is in line with the ndings of a 331% annual incidence among nurses in Southampton, United Kingdom (UK) (Smedley et al. 1997). Most current LBP episodes were of an acute type (less than 2 weeks); this, again, was similar to the results of other studies (Toroptsova et al. 1995, Hillman et al. 1996). In addition, as in previous studies (Frymoyer et al. 1983, Toroptsova et al. 1995), LBP was frequently described as a dull pain. Although nearly half the cases rated their recent LBP as
435

Physical inactivity in leisure time

Nurses who reported moderate or higher levels of leisuretime exercise experienced similar LBP symptoms to those who were categorized as sedentary (Table 2). Twenty nurses (357%) with new LBP, and 42 (477%) without new LBP belonged to the sedentary group.

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Y.B. Yip Table 4 Work stress and physical leisure activity among nurses with and without new low back pain

Psychosocial factors in the work place (a) Psychological stress related to work Relationships with colleagues Always satised/frequently satised Occasionally satised/never satised Relationships with senior or supervisor Always satised/frequently satised Occasionally satised/never satised Satised with work (tasks) Always satised/frequently satised Occasionally satised/never satised Feel stressed at work Occasionally/never stressed Always/frequently feel stressed Enjoy your work Always/often enjoy my work Occasionally/never enjoy my work Total work stress score (above ve factors), median (range) (b) Stress General Health Questionnaire score, median (range) Headache Never Occasionally Fatigue Never Occasionally Usually Low mood Never Occasionally (c) Physical activity in leisure time Active Underactive Sedentary

Nurses with new low back pain n 56 (%)

Nurses without low back pain n 88 (%)

P value

39 (696) 17 (304) 26 (464) 30 (536) 21 (375) 35 (625) 39 (696) 17 (304) 18 (321) 38 (679) 13 (817)

72 (818) 16 (182) 46 (523) 42 (477) 42 (477) 46 (523) 67 (761) 21 (239) 33 (375) 55 (625) 12 (716)

009

061

030

044

059 015

22 (1732)

22 (1735)

040

24 (429) 32 (571) 6 (107) 32 (571) 18 (321) 28 (500) 28 (500) 7 (125) 29 (518) 20 (357)

52 (591) 36 (409) 12 (136) 61 (693) 15 (170) 36 (409) 52 (591) 10 (114) 36 (409) 42 (477)

006

011

029

035

For continuous data, P-value is calculated by MannWhitney test. For categorical data, P-value is calculated by chi-square test. *P 005; SEM, standard error of mean.

being at least moderate, about half of these had undergone no treatment (including self-prescribed) at all. These ndings also correspond with past studies (Carey et al. 1996, Hillman et al. 1996).

Work activities and new LBP

The extent of the association between new LBP and material and patient handling factors was also examined. In line with previous studies (Videman et al. 1984, Harber et al. 1985, Venning et al. 1987, Stobbe et al. 1988, Vasiliadou et al. 1995, Smedley et al. 1997) and my baseline results (Yip
436

2001), my prospective results found a relationship between assisting patients in ambulating and new LBP. Previous studies in Hong Kong (French et al. 1997, Ho et al. 1997) found that transferring and lifting patients without an assistant were the two main factors, which nurses believed contributed to their LBP. Why does assisting patients in ambulating or walking increase the risk of new LBP? Nurses have expressed difculty in conforming to correct client transfer procedures when catering for the different characteristics of their clients. Engkvist et al. (1995) and

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Nursing and health care management and policy Table 5 Multivariate* logistic regression analysis of independent work-related risk factor(s) Age-adjusted RR (95% CI) P value

Work and lifestyle factors for new LBP in nurses

Work stress and new LBP

Of the four psychological work variables studied, only poor work relationships with colleagues were related to new LBP. Bigos et al. (1991), Magnusson et al. (1996), Van der Weide et al. (1999) and Torp et al. (2001) have reported similar associations. Papageorgious et al. (1997) found that getting along with colleagues at work was more important for women than men. In a teamwork-based occupation like nursing, it seems surprising that poor work relationships do not cause difculties with balance during patient handling. Being worried about how a wrong movement might injure their back and concern about being unable to do things because of risk of injury were two common reported concerns of those with LBP in a recent study (von Korff & Moore 2001). The higher incidence of LBP among nurses who had been working in their current unit for less than 1 year probably reects some degree of adaptation to the new working environment, particularly in engaging with new types of patients and working with new colleagues. Among nurses with LBP, these worries may make an already poor work relationship even more tense. Social support by colleagues is important. Low social support has been reported as a risk factor for low back complaints, especially in teamwork occupations such as nursing (Bernard 1997). Co-worker support may be an important factor in how pain is perceived and coped with (Torp et al. 2001), and how work is shared. Alleviating the impacts of these psychosocial work characteristics might involve improving both working relationships and the skill to cope with stress. Unfortunately, the topic of improving these psychosocial factors in the workplace is seldom included in on-the-job training programmes.

Variables Current ward experience >2 years 12 year(s) <1 year Bend to lift an item from oor level Lowest tertile Middle tertile Highest tertile Relationship with colleagues Always satised/frequently satised Occasionally satised/never satised Assist patient while ambulating Lowest tertile Middle tertile Highest tertile

100 (reference) 180 (064, 398) 290 (112, 783) 100 (reference) 066 (025, 175) 276 (106, 722) 100 (reference) 252 (103, 568) 100 (reference) 210 (088, 501) 087 (030, 248)

0314 0029

0400 0038

0037

0096 0789

*Backward stepwise logistic regression including other variables included in the table and self-reported age in the baseline study. Including assist patient while ambulating in the model, as it is the variable which is the independent risk indicator for low back pain in our baseline results and had P 005 in the univariate analyses in the 12 months follow-up among physical work activities; RR, relative risk. 95% condence interval. P-value of Wald chi-square statistics.

St-Vincent et al. (1999) reviewed transfer accidents in hospitals. Both suggest that some of the accidents involved stability problems during handling. Stability may have been compromised because the patient was difcult to control or because there was a problem of co-ordination or synchronization with a co-worker (St-Vincent et al. 1999). Engkvist et al. (1995) highlight the fact that half of these accidents were related to the condition or actions of the patient, who either became weaker, was agitated, moved unexpectedly, or resisted transfer or ambulation. Unfortunately, stability and how to ambulate patients with a co-worker are not extensively integrated into current handling training programmes. In line with previous studies (Buckle 1987, Pheasant & Stubbs 1992, Chiou et al. 1994), I found that bending to lift an item from oor level increased risk of LBP. Postures that involved prolonged forward exion of the trunk were of particular concern, as Ho et al. (1997) found that the majority of local nurses were required to bend during their work. Pressure on intervertebral discs increases when nurses bend forward or to the side during lifting (Pheasant & Stubbs 1992, Chiou et al. 1994). There is an urgent need to evaluate these bending postures ergonomically so that they can be diminished or modied.

Sedentary lifestyle
As in past studies (Leino 1993, Rohrer et al. 1994, Young et al. 1995, Kujala et al. 1996), there was no conclusive evidence of a relationship between physical inactivity and the occurrence of new LBP among nurses in my study. I adopted the classication of sedentary if respondents activity did not meet the recommendations of public guidelines (King et al. 2000, Sarkin et al. 2000) on physical activities. I did not target the effect of individual sports or exercise on LBP, except for walking and climbing stairs. A future study may need to focus on degree of sport activity and its relationship to the rate of LBP. Most previous studies of LBP have been retrospective or cross-sectional. By using a prospective design I avoided having to rely on participants distant memory for the reporting of

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Y.B. Yip

What is already know about this topic

Low back pain is common among nurses. Common nursing work activities have been identied as important physical risk factors for low back pain. Psychological stress at work has also been reported as a common factor in low back pain among nurses.

Kong being comparatively new on a ward, bending frequently during work and having poor work relationships with colleagues were independent predictors of new LBP, but a lack of physical leisure activity did not predict LBP. Training for high-risk work activities and ergonomic assessment of awkward work postures are essential. Moreover, relaxation and team-building workshops for nurses, especially those who are relatively new to a ward, are recommended.

What this paper adds

A high proportion of nurses reported experiencing new low back pain. Being comparatively new on a ward, bending frequently during work and having poor relationships with colleagues are independent predictors of new low back pain. Training for high-risk work activities, ergonomic assessment of work postures, and relaxation and teambuilding workshops may help to reduce the incidence of back pain.

Acknowledgements
I would like to acknowledge the support of the NHS Department Research Committee for this study, and would also like to thank all members of the LBP research team. I also acknowledge the programming assistance of Ms Chan Po Ming, Ms Tam Chung Ying, and Mr Ian Dunn for English proofreading and suggestions on renement of the manuscript.

References
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Conclusion
My ndings have important implications for the prevention of occupational back pain, especially in nurses. They suggest that LBP is a common problem in the population of nurses in Hong
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