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International Journal of Nursing Practice 2015; 21 (Suppl. 2), 108114

ORIGINAL ARTICLE

Occupational-related back pain among


Jordanian nurses: A descriptive study
Tagreed O Shawashi MSN RN
Teacher, Nursing Faculty, Clinical Department, University of Jordan, Amman, Jordan

Maha M Subih MSN RN


Assistant Professor, Nursing Faculty, Clinical Department, University of Jordan, Amman, Jordan

Lourance Abdel Razzaq Al Hadid RN MSN PhD


Assistant Professor, Nursing Faculty, Al Isra Private University, Amman, Jordan

Mohammad Abu Adas MSN RN


Lecturer, Nursing College, King Saud University, Riyadh, Kingdom of Saudi Arabia

Accepted for publication April 2013

Shawashi TO, Subih MM, Al Hadid LAR, Abu Adas M. International Journal of Nursing Practice 2015; 21 (Suppl. 2):
108114
Occupational-related back pain among Jordanian nurses: A descriptive study

Back pain is the leading cause of disability, decreased physical performance at work and absenteeism. Activities leading to
the occurrence of back pain include patient transfer and long standing hours. This study aimed to explore the prevalence
and determine the activities responsible for the presence of back pain among Jordanian nurses. A descriptive cross-
sectional study was conducted on a convenience sample of nurses from governmental hospitals in Jordan. A self-report
questionnaire was developed by Stubbs et al. and Harber et al. A descriptive method using mean, standard deviations and
percentages was used, in addition to chi-square tests. Baseline findings indicated that more than three-quarters of the
nurses studied suffered back pain during their work. Among nurses with back pain, about a fifth of them reported it to
administration. The highest percentage of back pain was among critical care nurses. Further, the static factors contributed
less commonly to back pain compared with the dynamic factors. Nearly half the participants with back pain reported taking
days off more frequently. Jordanian nurses demonstrated one of the highest frequencies of back pain compared with other
studies. Focus should be placed on education programmes about the appropriate body mechanics.
Key words: back pain frequency, dynamic factors, Jordan, static factors.

INTRODUCTION hospital settings.1 It is a problem that is widespread among


Back pain is one of the top 10 work-related musculo- nurses.1 Back pain can be defined as all conditions of pain,
skeletal disorders, with incidence rate of 9% in ache, stiffness or fatigue localized to the back, related to
nursing practice.2 Generally, it is the leading cause of
disability, decreased physical performance at work and
Correspondence: Tagreed Osama Shawashi, Faculty of Nursing, absenteeism in the working populations.35
University of Jordan, Amman 11942, Jordan. Email: tagreed_l@ Back pain is not exclusive to a unit or a country. It is a
yahoo.com serious problem affecting nurses in many countries like

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Occupational-related back pain 109

Italy which has a reported prevalence rate ranging from international study showed that approximately 40% of
33% to 86%. It has also been reported to be as high as nurses had experienced at least one injury or illness, and
76% among nurses in the Netherlands, and 77% in 80% had experienced back pain which was not generally
Turkey.6,7 In Asia, the prevalence of back pain among reported.11
Iranian nurses was 50%,8 66% among Taiwanese nurses,9 Back pain among Jordanian nurses is poorly understood
71.3% among Japanese nurses and 80% in the Philip- in terms of its prevalence and related factors. Hospitals in
pines.10,11 In Africa, the reported prevalence of back pain Jordan do not collect data on the reported occupational
among Nigerian and Ethiopian nurses was 67.5%.12 In the back pain among nurses. This, in turn, has created a gap in
Middle East, limited information is available about the the knowledge concerning this problem.
prevalence of this problem. One study conducted in Exploring the prevalence, risk factors and activities
Kuwait showed that 70.9% of nurses had complained of responsible for the presence of work-related back pain
back pain.13 among nurses might promote constitutional proactive
Among nurses, back pain seems to be an issue of plans to prevent the frequent occurrence of back pain and
concern to nursing practice and research. Previous studies determine the negative impact it has on the health-care
showed that back pain is prevalent among nurses.2 Nurses services and nursing personnel. Thus, this study aimed to
are at higher risk of back pain compared with other health- explore the prevalence, risk factors, and activities respon-
care professionals and hospital staff.13,14 This could be sible for the presence of occupational back pain among
related to the nature of the nursing profession in which Jordanian nurses, whereas the specific objectives were to:
nurses are demanded to perform several muscular duties recognize the frequencies of back pain among Jordanian
such as lifting, pushing and pulling of patients requiring nurses, identify which static and dynamic activities gener-
assistance.6 ate back pain, name which shift nurses are exposed more
Activities leading to the occurrence of back pain to back pain, study the impact of years of experience on
include patient transfer,9,15 and long standing times.2,16 prevalence of back pain, explore if there is association
Other factors were work setting, manual handling, between smoking, standing for a long time and body
weighty lifting, bending recurring work and exhausting weight on nurses back pain.
tasks.2,13,17 Intrinsic personal factors such as psychosocial
factors might lead to back pain, such as tobacco smoking,
no exercise and overweight.2,18,19 Nursing activities that METHODS
involve direct patient contact and known as patient- Study design
oriented tasks are mainly divided into two types of A cross-sectionaldescriptive design was used in this
actions: dynamic and static. These activities have influ- study.
enced nursing complaints of back pain.20
Dynamic patient-oriented tasks are patient contact
activities that involve movement, whereas static patient- Sample and setting
oriented tasks are those patient contact activities in A convenience sample consisted of 150 nurses working in
which the nurse maintains a fixed antigravity posture for different areas of critical and general wards from two
at least 30 s, and in which there is no move from the major (governmental) hospitals in Jordan (with 400 beds
patient.20 for each and occupancy rate around 85%), which were
The frequency of musculoskeletal disorders among randomly selected from 14 referral hospitals in Jordan.
nurses especially back pain has been studied over the past Sample size estimated using G power (version 3.1.5,
10 years for its impact on the health-care system.21 Back Heinrich-Heine-Universitt, Dsseldorf, Germany) that
pain among nurses have indirect costs that include brief met the criteria (90% power, medium effect size, alpha
training and hiring of substitute personnel, higher official 0.05), adding 10% attrition rate, showed the need for 130
fees to the substitute, overtime payment to replace the but we collected 150.
injured nurses, time loss costs to maintain processing and Inclusion criteria for nurses are as follows: nurses with
decreased productivity following traumatic event.22 direct contact with patients care, above 20 years old,
Occupational injuries and related disabilities exacerbate more than 3 months of experience(as general orientation
the nurses turnover and the nursing shortage. A previous programme requires 3 months for new nurses to be fixed

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110 TO Shawashi et al.

in their units or wards); whereas exclusion criteria was Ethical consideration


having any back pain before commencing nursing. Approval from the ethical research committee in the
Faculty of Nursing at The University of Jordan was taken,
Data collection technique then targeted hospitals approval was obtained. The
The study was approved by the Research Committee at researcher posted announcement of the study on the
the University of Jordan/Faculty of Nursing and from the station board; nurses who expressed interest contacted
targeted hospitals. Head nurses of targeted hospitals help the researcher and were given sealed envelopes containing
as facilitators for approaching nurses. An announcement questionnaires with cover letter, which included the
on the board at the nursing station was posted. Returned purpose of the study, procedure, significance and contact
questionnaires mean acceptance of participation. Ques- number for any needed explanations, with clarification
tionnaire copies were distributed to 250 participants over that there will be no risks/harm for voluntary participa-
a 2-month period (from May to July 2010). From these tion. No names were required and confidentiality was
250 questionnaires, only 150 questionnaires were com- guaranteed, as data will only be used for research purpose.
pleted, with 60% response rate, which might be consid- Participants were informed that they can withdraw at any
ered low due to absence of incentives for participation and time, and they can have a copy of the results if requested
nurses usually being overloaded and do not have time to as a benefit from the participation.
fill up questionnaires.
Data analysis
The data analysis used a quantitative method. All collected
Instrument
data were organized and summarized by descriptive
The instrument was adopted from an original 13-item
statistics (measures of central tendency, dispersion and
questionnaire (developed by Stubbs et al. and Harber
percentages), in addition to chi-square test to compare
et al.).23,24 After obtaining approval from the authors, the
the differences among some demographic variables with
questionnaire was translated into English by a profes-
the prevalence of back pain.
sional. The instrument was translated from English to
Data were checked for accuracy and entered on the
Arabic language, and then back-translation was done by
computer; 1020% of entered data was taken and com-
another independent researcher. The two English forms
pared with original questionnaires. Statistical Packages
(the original and the translated) were compared in terms
for the Social Sciences version 16.0 software (SPSS 16.0,
of conceptual rather than literal meaning of the items.
IBM Corporation, Armonk, NY, USA) was used for data
A pilot study was conducted on 25 nurses to review the
analysis.
questionnaire for clarity and to verify whether the voca-
bularies used were correctly understood. Validity of the
instrument by confirming the relevancy, clarity and impor- RESULTS
tance of items was assured by three doctorate-holder Demographic findings
nurses who were experts in the area of research concerning As shown in Table 1, the majority were female (64.6%,
pain. Then for reliability, the internal consistency was n = 97) and younger than 40 years (93.3%, n = 140),
measured for the total scale (Cronbachs = 0.72). The with range from 23 to 51 years (Mean 35 SD 5.2). Most
questionnaire took 1015 min to complete. Nothing had of the nurses were from intensive care unit (ICU) setting
been changed. (35.3%, n = 53), and almost two thirds were single
The questionnaire consisted of three parts. The first nurses (58.7%, n = 88). Three quarters of the partici-
part asked about demographic data including age, gender, pants held baccalaureate degree (76.7%, n = 115),
marital status, unit, height and weight (BMI, body mass 21.3% (n = 32) were smokers, and 78.7% (n = 118)
index). The second part asked about pain: the first episode spent their duty standing for a while; finally, only 20%
of back pain, usual sites of back pain and consequences (n = 30) of nurses were overweight, with BMI from
associated with back pain. The third part was the dynamic 25 to 29.
and static patient-oriented activities that contributed to Nurses who were smokers show no significant differ-
back pain. Further, participants who suffered back pain ence of back pain in comparison with non-smokers
were asked to identify the usual site of pain on a diagram. (2 = 5.2, P = 0.21); also, nurses who were standing

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Occupational-related back pain 111

Table 1 Demographic characteristics (n = 150) Table 2 Frequencies of back pain among nurses

Factor No. (%) Variable Response No. (%)

Gender Male 53 (35.4) Prevalence of back pain Yes 115 (76.7)


Female 97 (64.6) after commencing No 35 (24.5)
Age (years) < 25 65 (43.3) nursing
2539 75 (50) Frequency of back pain Daily 25 (23.1)
40 and above 10 (6.7) Once a week 41 (38)
Work setting ICU 53 (35.3) Once a month 25 (23.1)
Med/Surg ward 46 (30.6) A few times a year 15 (13.9)
Pediatric 16 (10.7) < once a year 2 (1.9)
Maternity ward 13 (8.7) Back pain and years of <2 26 (24.1)
Emergency department 12 (8) experience in nursing 2 to less than 5 32 (29.6)
PACU-OR 10 (6.7) 5 to 8 17 (15.7)
Marital status Married 61 (40.6) >8 33 (30.6)
Single 88 (58.7) First episode of back Day duty 39 (36.1)
Divorced 1 (0.7) pain Night duty 52 (48.1)
Type of work Full-time employee 129 (86) Both 17 (15.7)
Part-time employee 21 (14) Back pain and present ICU 39 (36)
Academic degree Bachelors degree 115 (76.7) area of work Med/Surg ward 30 (27.8)
Diploma 35 (23.3) Maternity 11 (10.2)
Pediatric 10 (9.4)
ICU, intensive care unit; Med/Surg ward, medical/surgical PACU-OR 9 (8.3)
ward; PACU-OR, post-anaesthesia care unit and operation room. Emergency department 9 (8.3)

ICU, intensive care unit; Med/Surg ward, medical/surgical


for a while vs. those who did not, showed significant ward; PACU-OR, post-anaesthesia care unit and operation room.
difference (2 = 4, P = 0.43). Furthermore, nurses who
were overweight (high BMI: 2529) showed no significant Table 3 Reported sites of back pain (n = 115)
difference of back pain compared with those who were
not overweight (2 = 1.5, P = 0.15). Site of back pain No. (%)

Back pain frequency and sites Upper back and neck 32 (29.6)
To be sure that all nurses were complaining of back pain Mid-back 19 (17.6)
Low back 91 (84.3)
after practising nursing and not prior (pain that is not
Buttocks and legs 19 (17.6)
from the nursing practice/activities was excluded), the
participants were asked in the questionnaire when they
Participants reported having more than one area of pain.
experienced the first episode of back pain and 76.7%
(n = 115) reported it happened after they practised
nursing; seven nurses reported experiencing back pain
before being nurses and so were excluded, as mentioned ICU nurses showed the highest percentage of back pain
in the exclusion criteria. As shown in Table 2, nearly (36%, n = 39). However, chi-square test was also carried
half of the participants said that their first episode of out to examine the difference of back pain among different
back pain happened during the night shift (48.1%, years of working experiences and different working areas,
n = 52). Frequency of back pain mostly reported was and showed no significant difference (2 = 3.3, 6.4,
once a week (38%). P = 0.18, 0.13, respectively).
The highest frequency of back pain was among nurses Table 3 shows that most of the nurses reported pain
with experience of more than 8 years (30.6%, n = 33). when it occurs in the lower area of the back (84.3%,

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Table 4 Impact of dynamic factors on nurses reported back pain bed without assistance (52.8%, n = 57) as the most
(n = 115) frequent activities leading to back pain.
The static factors contributed less commonly to back
Dynamic factor No. (%) pain. The nurses who reported stooping and squatting
as a contributing factor to their back pain were 38%
Lifting patient within bed with assistance 42 (38.9) (n = 41) for each. Further, when asked whether they
Lifting patient within bed without assistance 57 (52.8) reported having back pain to administrators or nursing
Lifting patient from floor with assistance 28 (25.9)
ward manager, 78.7% (n = 85) of them stated that they
Lifting patient from floor without assistance 51 (47.2)
did not report this problem.
Transferring patient (bed to chair; bed to bed) 68 (63)
Ambulating patient 39 (36.1)
Restraining struggling patient 33 (30.6) DISCUSSION
Giving assistance when patient starts to fall 53 (49.1) Findings in this study showed that most nurses suffered
from back pain; prevalence of back pain among Jordanian
nurses was higher than that reported in Kuwait.13 Majority
of the nurses had pain in the low area of the lumber
Table 5 Impact of static factors on nurses reported back pain
region, consistent with other studies which showed that
(n = 115)
lower lumbar discs, L4L5 and L5S1, have been
Static factor No. (%) reported to bear the greatest mechanical stress, compres-
sion force and the greatest degenerative changes.23 These
Leaning over patient 34 (31.5) compression forces are generated by heavy physical
Stooping 41 (38) work, manual lifting and prolonged static work posture.
Squatting 41 (38) This explains why most nurses said that stooping and
squatting were the most likely static factors contributing
to back pain.
Table 6 Impact of their back pain on nurses career (n = 115) Stooping is warned against in almost all nursing training
scenarios; there is some indication here that either inad-
Impact of back pain No. (%) equate training or personal neglect might have contrib-
uted to the problem.12 In addition, there is evidence that
Restriction of activity 36 (33.3) nurses perform inappropriate practices, which include
Transfer to another position 28 (25.9) inappropriate body mechanics and improper posture
Thinking to leave nursing 40 (37) when making in or out-of-bed patient mobilization.7 That
Taking many days off 52 (48.1) is why transferring the patient and lifting a heavy
patient within the bed without assistance were the top
dynamic factors contributing to back pain. Both factors
indicate that suitable techniques for lifting and carrying
n = 91). The back pains impact on nurses career was were not being adopted in nursing practice.
mainly by taking many days off from work (48.1%) as A strong relationship between smoking and back pain is
shown in Table 4. documented in the literature.2,18,19 However, smoking in
this study did not support these studies; this might be
Static and dynamic factors because nurses who experienced back pain and were
Participants were asked to identify patient contact activ- smokers represented 21.4% (n = 23), which is consid-
ities they believe contributed to their back pain. The ered relatively a small percentage. Overweight (high BMI)
number of responses was not constrained (meaning the was found to be statistically insignificant in our study; this
participant can select more than one answer/activity); finding is opposite to some literature,19,25 but is consistent
four activities were selected by participants and were cat- with other studies.2
egorized into dynamic (Table 5) and static (Table 6). The effects of long standing were found to be statisti-
Majority chose Transferring patient (63%, n = 68) from cally insignificant, which was inconsistent with some
the dynamic factors, followed by lifting patient within studies (Karahan et al.).2 The majority of nurses with back

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Occupational-related back pain 113

pain conduct many tasks while standing. Long standing of back pain among hospital staff internationally, so that
periods usually increase pressure on the lumbar area best practice can be disseminated and costs of back pain
leading to lower back pain, which is the most prevalent reduced.
pain reported in this study.
The impact of years of experience on prevalence of
back pain was found to be statistically insignificant. ACKNOWLEDGEMENTS
Experienced nurses are supposed to be more qualified in We would like to thank colleagues Basel Abdel-Qader,
performing caring activities, without harming themselves, Osaid Rasheed and Zyad Taher for their sincere efforts to
than the younger ones.18 complete this study. Also, we do not have any funding or
An alarming finding was the high percentage of under- financial grants.
reported incidence of back pain to the administrative
body, thus leading to more serious problems later. REFERENCES
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