Effectiveness of a multidimensional intervention program in improving occupational musculoskeletal disorders among intensive care units nurses: a cluster controlled trial with follow-up at 3 and 6 months

doi:10.21203/rs.3.rs-54677/v1

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Effectiveness of a multidimensional intervention program in improving occupational musculoskeletal disorders among intensive care units nurses: a cluster controlled trial with follow-up at 3 and 6 months

https://doi.org/10.21203/rs.3.rs-54677/v1

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published 20 Mar, 2021

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Background: Intensive care unit (ICU) nurses are at high risk for work-related musculoskeletal disorders (WRMDs). Data on occupational injuries indicate the significance of WRMDs among ICU nurses. Intervention programs have previously been developed to reduce WRMDs, but different intervention methods need to be adopted for different groups of people. This study aimed to evaluate the effectiveness of a multidimensional intervention program to prevent and reduce WRMDs in ICU nurses.

Methods: The study was designed as a two-armed cluster controlled trial with an intervention group and a control group. The clusters were independent hospital ICUs, and the participants consisted of registered nurses. By cluster random sampling, 89 nurses from 2 ICUs were assigned to the intervention group, and 101 nurses from 2 other ICUs were assigned to the control group. A multidimensional intervention program based on previous studies was designed. This program combined improving risk perception, health behavior training, and promoting a safe working environment. The multidimensional intervention program was implemented in the intervention group, whereas the routine specialist training was implemented in the control group. Baseline and follow-up (3 and 6 months) data were collected using self-reported online questionnaires. The primary outcome was the report rate of WRMDs in the past 7 days. Secondary outcomes were risk perception, health behavior applied, and perception of a safe working environment. The data were statistically analyzed using SPSS 19.0.

Results: A total of 190 nurses provided 3 recorded outcome measurement (intervention group N=89 (94.68%); control group N=101 (94.39%)). After 6 months, the intervention group experienced significant improvement relative to the control group in the report rate of WRMDs in the past 7 days (OR=0.512, p =0.038), risk perception (OR=0.517, p <0.001), health behavior training (OR=0.025, p <0.001), and perception of a safe working environment (OR=1.637, p =0.024).

Conclusion: The multidimensional intervention program was superior to routine specialist training in preventing the occurrence of WRMDs in ICU nurses. WRMD training should include multifaceted approaches and pay increased attention to specific aspects of the departmental function.

Nursing

musculoskeletal disorder

intensive care unit

nurses

intervention study

Work-related musculoskeletal disorders (WRMDs) are injuries to the musculoskeletal system that result from exposure to the work environment[1]. For nurses, WRMDs are major occupational health problems. The 12-month prevalence of WRMDs among nurses worldwide ranges from 40% to 85%; the difference is attributed to variations in national culture, medical environment, and the nature of the job[2–5]. The resulting disorders can lower the quality of life and increase the sick working days of nursing staff[6, 7]. In China, a large number of nurses often work with disorders because of a shortage of nursing staff and a lack of awareness of the cumulative damage of WRMDs. In a survey of WRMDs among Chinese nurses, the 12-month prevalence of WRMDs was 77.43%, but only 9.39% of nurses took a sick leave due to MWSDs[8].

An intensive care unit (ICU) is a place that provides rescue and treatment for critically ill patients in China[9]. Patients in ICU are often immobile with severe physical weakness and limited ability to care for themselves. Nurses are required to complete a large amount of professional treatment, rescue, and care every day, rendering them vulnerable to developing WRMDs[10, 11]. Our recent cross-sectional survey showed that WRMDs have a prevalence of 97.1% among ICU nurses in Chinese tertiary hospitals, which was close to that (95%–98%) among ICU nurses surveyed by Zhang et al.[12]. WRMDs negatively affected the well-being and work of ICU nurses, and this effect was significant[13]. Chen and Li showed that 28.9% of ICU nurses in China filed a leave of absence or requested for transfer to another unit because of low back pain[14]. Therefore, WRMD prevention is important for the health of nurses and the stability of ICU teams.

Many single intervention programs have been implemented to reduce the risk of WRMDs, including patient handling and mobility program[15], ergonomic intervention[16, 17], work-related psychosocial coaching[18], health promotion and health protection intervention[19, 20], exercise and physiotherapy[21, 22], and so on. However, a systematic review of prevention and reduction of WRMDs among nurses indicated that evidence was limited for each intervention type[23]. Tullar et al. conducted a systematic review of interventions for musculoskeletal injuries in health care workers and reached a similar conclusion—that is, that training alone or exercise alone exerts no effect on musculoskeletal health[24]. Therefore, a broader perspective is needed in the prevention of WRMDs. Occupational risk factors for WRMDs are not independent. The occurrence of WRMDs in nurses may be influenced by physical factors, as well as environmental factors, organizational factors, and preexisting WRMDs symptoms.

Some studies have explored the combination of two or more single-factor intervention programs for WRMDs into a multidisciplinary intervention program, which may be preferable[25, 26]. However, no standard has been set for the inclusions of a successful WRMD multidimensional intervention program and relevant evidence is limited[23]. Moreover, research is rarely reported on multidimensional intervention programs, which provides a specialized program based on the needs of a specific group of nurses and focuses on the factors affecting WRMDs in that group. It is possible when a multidimensional intervention program can be customized based on work characteristics, ergonomic equipment available in the workplace, medical environment characteristics, and national cultural characteristics, which can be more closely targeted to prevent injuries and the recurrence of WRMDs. This study aimed to evaluate the effectiveness of such a multidimensional intervention program.

More specifically, this study intended to evaluate the effectiveness of a multidimensional intervention program in reducing WRMD symptoms among ICU nurses in China. Our previous cross-sectional survey identified the risk factors of WRMDs among ICU nurses in Chinese tertiary hospitals: risk perception, physical factors (frequency of handling patients and physical workload), psychosocial factors (job stress), and workplace environmental factors [13]. Accordingly, a personalized and multidimensional intervention program was designed to reduce WRMDs symptoms, as reported by Chinese ICU nurses. The multidimensional intervention program consisted of three components: improvement of risk perception, health behavior training, and promotion of a safe working environment. Risk perception has been proposed as a determinant for preventive health behaviors in a number of behavioral theories[27]. Adequate perception of WRMDs can motivate the adoption of safe work behaviors[28, 29]. Health behavior programs are a constant concern as physical factors; they are among the main risk factors for WRMDs and have shown potential in numerous intervention studies[30, 31]. Environmental safety in hospitals is also one of the risk factors affecting the occurrence of WRMDs. A positive perception of working environment safety can effectively reduce the risk of occupational exposure[32]. The present study also provides evidence for research on multidimensional intervention programs.

Study design

This study was designed as a two-armed cluster controlled trial with an intervention group and a control group (Figure 1), where the clusters were independent hospital ICUs, and the participants consisted of registered nurses in clinical practice. In China, all nursing directors in public hospitals are required to organize an occupational health training program, including comprehensive training and routine specialist training[33]. Comprehensive training is uniform training of basic theories and skills for nurses by the hospital. Routine Specialist training is organized by the head nurse, conducted in the form of lectures once or twice a year depending on the occupational risks of the unit. Routine specialist training includes special disease care and information and training of occupational health risks[34]. After baseline data were collected (as described below), the participating ICUs were randomly divided into the intervention group and the control group. A two-month multidimensional training program was implemented in the intervention group, whereas only routine specialist training was implemented in the control group. Stratified randomization was not possible because the towns where the participants were staying were far apart, and the potential propensity to communicate with each other was present, considering the participants were working in the same hospital.

No other specific risks were associated with participating in this program other than those associated with the adoption of preventive actions. The Research Ethics Committee of X University approved this study (2017025).

Setting

The programs in the intervention group and the control group were implemented in ICU rooms for the convenience of the nurses. All ICUs participating in the study had similar levels of health care complexity: 1 patient for every 2.5 to 3 nurses on average, each with experience in routine specialist training, and had similar professional training methods and contents.

Recruitment of ICUs

ICUs had to meet the following criteria to ensure the selection of appropriate clusters and the implementation of the intervention: (1) the ICU was located in a tertiary public hospital; (2) the ICU admitted mixed cases (i.e., ICUs with critically ill patients transferred from any department); (3) commitment and explicit interest to implement the programs and its evaluation were shown by the hospital nursing directors, head nurses, and nurses; and (4) the ICU was exposed to significant risks of WRMDs, as assessed by the previous survey (prevalence of WRMDs > 90%).

The units were recruited from ICUs in Hunan Province that participated in the previous cross-sectional survey. Under the aforementioned criteria, 4 mixed ICUs in 4 tertiary public hospitals were recruited. An independent researcher randomly assigned the 4 ICUs to the intervention group (2 ICUs) or to the control group (2 ICUs) by using the random grouping function in Excel.

Recruitment of participants

During recruitment, the purpose and methods of the intervention study were explained to the participants in each cluster before they were assigned to their respective groups— the intervention group or the control group—was disclosed. Informed consent and the baseline questionnaires were obtained from each participant in ICU nurses. After the questionnaires were accomplished and returned, the 4 units were randomized, and the participants were informed of their conditions as the intervention group or the control group. Subsequently, the intervention started. Follow up questionnaires were administered at 3 and 6 months afer the end of the intervention.

Eligibility criteria of participants

The inclusion criteria were as follows: registered nurses, including nurses who were on sickness absence and those who were engaged in patient care daily and volunteered. Nurses who were pregnant and performed only administrative work were excluded from this study.

Intervention

The intervention group implemented the multidimensional intervention program, covering three aspects: improvement of risk perception, health behavior training, and promotion of a safe working environment. The control group received routine specialist training on WRMDs, including two lectures on WRMDs and safe working environments. The schedule of the specific interventions is presented in Figure 2. A working group was organized for each hospital ICU. The intervention group included a head nurse, an ergonomics specialist, an orthopedist, a nurse representative, and a researcher responsible for the development and implementation of the intervention. The control group included a head nurse, a nurse representative, and a researcher responsible for routine specialist training on WRMDs.

Improvement of risk perception of WRMD

Risk perception plays an important role in preventing occupational risks and can be used as an incentive to promote safe work behaviors[35]. Measures to improve risk perception included the following: (1) A lecture on WRMDs, consisting of a session for 40 min on the WRMD course that had been determined by the working group. The lecture covered the type, symptoms, epidemiology, risk factors, and consequences of WRMDs and was presented by clinical nursing experts in WRMDs with considerable years of experience. (2) WRMD Awareness Month. The Health Belief Model holds that individual behavior is influenced by cues that motivate people to change their behavior, such as media reports, advice from others, and reminder brochures[27, 28]. The 5th to 8th week of the intervention program was assigned as the WRMD Awareness Month. The working group distributed brochures on WRMDs to nurses. The brochures covered the concepts of WRMDs, influencing factors, protective exercises, and application of the principles of ergonomics. A competition on WRMD knowledge and skills was held during the awareness month. It focused on strengthening the knowledge and skills of nurses in preventing WRMDs. Nurses with excellent grades were rewarded.

Health behavior training

Some studies have shown that physical interventions, such as the use of ergonomic aids, training in patient handling, and physical activity, positively affect the reduction of musculoskeletal injuries and pain among nurses[23]. The health behavior training in our study included the following: (1) A 40-minute lecture on ergonomics. An ergonomic expert introduced the concept of ergonomics, research content, and related principles and applications of nursing practice. (2) Health behavioral guidance. A science-based guidance plan was developed by the working group and implemented in the intervention group. Specifically, the behavioral guide included suggestions on how to (i) move and carry bedridden patients, (ii) use slides when moving an awake patient from the bed to the wheelchair, carry and move objects, (iii) lift items, (iv) walk, squat, and turn around at work; (v) adopt the correct sitting posture; (vi) adjust the chair height for fit and comfort; and (vii) perform physical exercises. Each procedure was demonstrated and guided by ergonomics and clinical nursing experts. (3) Health behavior reinforcement and questioning. The Transtheoretical Model of Change holds changes in human behavior should undergo consolidation and recurrence[36]. Thus, a weekly session starting Week 5 was organized by the working group to reinforce the health behavior of nurses and solve problems. At the meeting, the nurses would review correct behaviors via scenario simulation and group discussion.

Providing a safe work environment

Poor perception of safety climate represents a stressor that may increase the number of WRMDs reported by employees[37]. On the basis of the inspection results and recommendations by the ergonomic expert and the clinical nurse expert, the working group proposed and implemented the following: (1) Lectures on a safe working environment, with each session 40 min long. A clinical nursing expert introduced management support for working safety, barriers to work safety, safety awareness training, teamwork, and communication. (2) An improvement plan for an ICU layout. Work chairs (5–7) were replaced with height-adjustable chairs for nurses of different heights, a foot stool (30 cm high) was provided to help nurses reach for items at a higher location, and slides were purchased to assist nurses when transferring patients from the bed to the wheelchair.

Routine specialist training in WRMDs

The control group received only routine specialist training, including: (1) lectures on WRMDs and a safe working environment, consisting of two sessions for 40 min each, which were consistent with the content of the intervention group. The training is updated yearly to meet the requirements for unit development.

Finally, all components of the intervention group and the control group required a leader to integrate, coordinate, and lead the research. The tasks involved communication, organizing meetings, and facilitating the implementation of the intervention.

Measurement

Data were collected using self-reported online questionnaires. The online questionnaire comprised 2 parts. The first part consisted of informed consent. If nurses were willing to participate in the study, they completed the succeeding questionnaire, but if not, the nurse closed the application. The second part was the questionnaire itself. Baseline demographic information was collected, including age, gender, height, weight, marital status, job title, education, and number of years in the ICU. Baseline and follow-up primary and secondary outcomes were collected, with follow-up conducted at 3 and 6 months.

This online questionnaire was developed using the Chinese-based questionnaire software Sojump (Sojump, Hu Xiao, China). The software generated an online link and a two-dimensional image code. By clicking on the link or scanning the two-dimensional image code, the nurses could enter and complete the questionnaire via the WeChat application on a mobile device. To prevent incomplete and duplicate data, the questionnaire contained mandatory fields and limited submission to one online questionnaire for every WeChat account. All respondents who completed the questionnaire received $5.0 Yuan (about US$0.71) as an incentive via the WeChat mobile payment red envelope function.

All sample data were exported from the Sojump software to SPSS 19.0 and were double-checked to identify inconsistencies and errors. Data on incomplete studies would not be used for statistical analysis.

Primary outcome

Report rate of WRMDs in the past 7 days

The Chinese version of Nordic Musculoskeletal Questionnaire[38] was used to measure self-perceived symptoms of WRMD in 9 regions of the body in the last year and the past 7 days. A diagram of the body was included to allow nurses to identify the affected areas. No checkmarks or multiple checkmarks were allowed. Baseline and follow-up (3 and 6 months) data were collected.

Secondary outcomes

Risk perception

Risk perception was assessed using the Chinese version of the Risk Perception of Musculoskeletal Injury measure developed by S. J. Lee et al. (2013) [39]. This tool was translated from English to Chinese by the researcher, with the permission of the author. The respondents estimated the risk of WRMDs as perceived by themselves or by other nurses in their respective units. A six-point Likert scale from 1 (extremely unlikely) to 6 (extremely likely) was used. The score was calculated as the mean of the 8 items; the higher the score, the greater the WRMD risk perceived.

Health behavior applying

Health behavior applying were measured using the Nursing Physical Factors Evaluation Questionnaire, including the frequency of patient handling (6 items) and physical workload (9 items). This tool was designed by the author for this study A five-point Likert-type scale from 0 (never) to 4 (very often) was used. The total score of the 15 items was considered as the final score; the higher the scores, the greater the ergonomic risk.

Perception of a safe working environment

The Chinese version of the Hospital Safety Climate Questionnaire[40] was used to measure the level of awareness regarding workplace and environmental safety, which was slightly modified to fit the context of this study. All items were answered using a four-point Likert-type scale from 1 (strongly disagree) to 4 (strongly agree). The score was calculated as the sum of the items; the lower the scores, the safer the environment was perceived to be. Baseline and follow-up (3 and 6 months) data were collected.

Additional details on the questionnaires are provided in another article on WRMDs by the author[13].

Data analysis

The data were statistically analyzed using SPSS 19.0 (IBM, NY, USA). Descriptive statistical analysis was used to summarize the demographic characteristics of the participants. Student’s t-test and the Chi-square test were used to determine whether a statistical difference existed between the intervention group and the control group at baseline. Analyses of the effectiveness of the primary outcome and the secondary outcome were to be performed after intervention for 6 months by using a generalized estimation equation (GEE). The subject variable was the number of nurses, and the internal variable was the time point. The model type (linear regression or binary logistic regression) was selected based on the type of outcome indicators. We first analyzed the single-factor GEE, followed by the multifactor GEE, including the demographic factors affecting the outcomes.

Study sample

A total of 201 nurses from 4 mixed ICUs in 4 hospitals were recruited from December 2017 to January 2018. These 4 hospitals were selected from the 20 tertiary hospitals in Hunan Province that participated in the previous cross-sectional survey. From the 2 ICUs, 94 nurses from 2 ICUs were assigned to the intervention group, and from the 2 remaining ICUs, 104 nurses were assigned to the control group by cluster random sampling. During the intervention, 5 nurses in the intervention group were lost to follow-up: 2 nurses resigned, 2 nurses transferred, and 1 nurse took a leave of absence due to pregnancy. Meanwhile, 6 nurses in the control group were lost to follow-up: 1 nurse quit voluntarily, 2 nurses left for training, and 3 nurses took a leave of absence due to pregnancy. Ultimately, 190 nurses provided 3 recorded outcome measurements (intervention group N=89 [94.68%]), control group N=101 [94.39%]). No significant difference in loss to follow-up was found between the two groups (χ²=0.074, p=0.862).

Baseline data

At baseline, no significant differences in demographic characteristics, except for education (Table 1), were found between the intervention group and the control group. Overall, male participants were underrepresented in both the intervention group and the control group. The average age was 28 for the participants in both groups. Most participants completed a bachelor’s degree and worked for less than 10 years. No significant difference in the prevalence of WRMDs was indicated between the two groups (χ²=0.710, p=0.824).

Intervention effects

Gender affected the report rate of WRMDs in the past 7 days (p=0.003). The GEE, including gender, indicated that the measures of the intervention group and the control group were statistically significant. Compared with routine specialist training, the use of multidimensional intervention programs reduced the risk of WRMDs by 48.8% (OR=0.512, p=0.038). No interaction between different measurement time and group (p=0.814). The results of the specific parameter estimation are listed in Table 2.

The GEE showed that the multidimensional intervention program improved the risk perception of WRMDs (OR=1.125, p<0.001) and health behavior applying (OR=1.637, p<0.001), relative to that of the routine specialist training. Interaction between different measurement times and groups (p<0.001). The results of specific parameter estimation are listed in Tables 3 and 4.

Age and ICU employment affected the perception of a safe working environment (p=0.047and p=0.032 respectively). The GEE, including age and ICU employment, indicated that the measures of the intervention group and the control group were statistically significant. The perception of an unsafe working environment in the control group was 1.637 times that in the intervention group (OR=1.637, p=0.024). No interaction between different measurement time and group (p=0.805). The results of specific parameter estimation are listed in Table 5.

The results revealed that compared with routine specialist training, the multidimensional intervention program more positively influenced the rate of WRMDs reported in the past 7 days and exhibited stronger sustainability in reducing such a rate. Consistent with the previous finding that multidimensional interventions are preferable to single interventions in reducing musculoskeletal disorders or the risk of subsequent injuries in nurses[17, 41, 42]. The reason for the stronger positive effect may be that the formulation of the intervention program was based on a previous investigation of influencing factors. Thus, adopting a customized multidimensional intervention program for a specific population is recommended.

Considering that the study duration was less than 1 year, we did not investigate the annual prevalence of WRMDs. Current research shows that intervention programs to effectively reduce the annual prevalence of musculoskeletal disorders in nurses are limited. The intervention program by Sharafkhani et al., which was based on the health belief model, effectively improved the health belief score of the nurses; however, no statistical difference was found in the prevalence of musculoskeletal disorders after intervention for 1 year[28]. Yan et al. used knowledge training and ergonomic intervention to reduce the occurrence of WRMDs among nurses in Xinjiang Province. The results showed that despite the reduction in the annual prevalence of WRMDs, no statistical difference was indicated[43]. The reason may be that no other staff was present to monitor the work behavior of the nurses or no benefit was perceived[44]. The development of a long-term approach to maintaining the effectiveness of intervention programs needs to be addressed.

Research shows that psychosocial factors play a significant role in the emergence and persistence of musculoskeletal disorders[45, 46]. In the current study, nurses obtained relevant knowledge of WRMDs and their consequences through lectures, effectively improving the risk perception of WRMDs. Training and lectures effectively increase awareness of safety and self-protection [47] and promote healthy practices among nurses[39]. The WRMD Awareness Month as a cue factor strengthens the belief in safe work behavior through brochure distribution and knowledge and skills competition[27, 28]. As part of multidimensional intervention, improving risk perception fully considers the effects of psychological factors on behavior and promotes the adoption of safe working behavior among nurses through changes in attitude and belief.

Many studies have shown that health behavior training can effectively reduce the occurrence of WRMDs among nurses[48, 49]. In the current study, we adopted ergonomics as the theoretical guide, combined with the work characteristics of ICU nurses, and guided nurses to take a scientific posture to engage in clinical nursing work. The transtheoretical model, which proposes that changes in behavior occur in stages, proposes that behavior may return to its original state[50]. We thus adopted intensive training to consolidate the effects of behavioral training. The results showed that health behavioral training effectively increased the number of nurses adopting health behavior and improved the short-term rate of WRMDs reported. This result is consistent with the previous evidence that courses on patient transport can significantly decrease the rate of short-term physical disorders. However, no significant difference in the reduction in physical disorders was determined between the baseline data and the data after 2.5 years[51]. Therefore, we recommend regular health behavior training to prevent musculoskeletal disorders. The appropriate period may be 6 months to 1 year.

A slide is a small auxiliary device used to transport a patient or move a patient from the bed to the wheelchair. Some studies support the use of slides as part of musculoskeletal injury prevention programs and can reduce the risk of musculoskeletal injuries for nurses[52, 53]. However, the current study showed the considerably low usage rate of slides (once every 2 days) among ICU nurses. The reason could be that most patients in ICUs could complete basic treatment and examination in bed, and the slide could be too slippery for certain patients.

Multidimensional interventions also effectively reduce the perception of an unsafe working environment among nurses. Nurses with a higher perception of a safe working environment have lower occupational hazard exposure and a lower incidence of musculoskeletal disorders[32, 54]. Studies on interventions for safe hospital environment are rarely conducted, which may be attributed to the relatively fixed working environment in ICUs, and financial and administrative support required to implement changes in the workplace[15]. Considering the aforementioned limitations, we focused on the scientific placement of objects and the use of low-cost assistive equipment. These changes to the work environment are visible and sustainable, as well as actively involve nurses, effectively reducing the perception of an unsafe working environment among nurses.

Throughout the intervention process, ICU nurses easily cooperate in intervention programs. Most people are willing to participate and insist on completing the process. However, some limitations require caution in interpreting the findings. First, the educational levels of the intervention group and the control group at baseline exhibited a significant difference, but education exerted no effect on outcomes. Thus, the multidimensional intervention program is preferred. Second, the study relied on the memory of the participants, which might have been influenced by information bias from errors of recall. Third, the study had a short time frame and did not investigate the annual prevalence of WRMDs, considering that no statistical difference in reducing the annual prevalence of WRMDs was indicated in current intervention studies. Therefore, we hoped to develop a multidimensional and short-term intervention program as part of an annual routine specialist training program for nurses.

For occupational health promotion, meticulous planning is essential in order to make interventions compatible with the daily work routine (e.g., shift work). Under these circumstances, the multidimensional intervention program seems applicable from time, financial, and organizational perspectives. Compared with rutine specilist training alone, the multidimensional intervention program helps in reducing the short-term reported incidence rate of WRMDs, improving the nursing risk perception, health behavior applying, and promoting a safe working environment.. Hospitals should acquire appropriate handling or transfer equipment to reduce the number of nurses carrying patients manually. Routine specialist training should include multifaceted approaches (lecture and health behavioral training) and pay more attention to the particularity of the department functions. In addition, we recommend conducting multidimensional interventions for WRMD in routine specialist training annually to regularly monitor nursing practices and enhance the risk awareness among nurses, rather than rely on a single intervention.

WRMDs; Work-related musculoskeletal disorders; ICU: Intensive care unit; GEE: Generalized estimation equation

Ethics approval and consent to participate

Ethical approval was obtained from the Research Ethics Committee of Xiang Ya Nursing School of Central South University,reference number: 2017025. Informed consent were collected from participants.

Consent for publication

Not applicable.

Availability of data and materials

The datasets used and /or analysed during the current study are available from the corresponding author on reasonable request.

Competing interests

The authors declare that they have no competing interests.

Funding

No funding was obtained for this study.

Authors’ contributions

SY participated in the study design and implementation of intervention programs, and was a major contributor in writing the manuscript. LL helped draft the manuscript, participated in the implementations of intervention programs, and participated in the data analysis. LQW, JQZ and BY participated in the data collection. YLL participated in the study design and contacted the participating hospitals. All authors read and approved the final manuscript.

Acknowledgements

The authors express sincere gratitude to all the intensive care units nurses who participated in the study, the chief managers of the hospital nursing departments, the head nurses of ICU. The authors also thank the ergonomics specialist and the orthopedist.

Freimann T, Coggon D, Merisalu E, Animagi L, Paasuke M. Risk factors for musculoskeletal pain amongst nurses in Estonia: a cross-sectional study. BMC Musculoskelet Disord. 2013;14:334. https://doi.org/10.1186/1471-2474-14-334.
Chiwaridzo M, Makotore V, Dambi JM, Munambah N, Mhlanga M. Work-related musculoskeletal disorders among registered general nurses: a case of a large central hospital in Harare, Zimbabwe. BMC Res Notes. 2018;11(1):315. https://doi.org/10.1186/s13104-018-3412-8.
Luan HD, Hai NT, Xanh PT, et al. Musculoskeletal disorders: prevalence and associated factors among district hospital nurses in Haiphong, Vietnam. Biomed Res Int. 2018; 2018:3162564. https://doi.org/10.1155/2018/3162564.
Zhang Y, Duffy JF, de Castillero ER, Wang K. Chronotype, sleep characteristics, and musculoskeletal disorders among hospital nurses. Workplace Health Saf. 2018;66(1):8-15. https://doi.org/10.1177/2165079917704671.
Younan L, Clinton M, Fares S, Jardali FE, Samaha H. The relationship between work-related musculoskeletal disorders, chronic occupational fatigue, and work organization: a multi-hospital cross-sectional study. J Adv Nurs. 2019;75(8):1667-77. https://doi.org/10.1111/jan.13952.
Schofield DJ, Callander EJ, Shrestha RN, Passey ME, Kelly SJ, Percival R. Back problems, comorbidities, and their association with wealth. Spine J. 2015;15(1):34-41. https://doi.org/10.1016/j.spinee.2014.06.018.
Richardson A, Gurung G, Derrett S, Harcombe H. Perspectives on preventing musculoskeletal injuries in nurses: a qualitative study. Nurs Open. 2019;6(3):915-29. https://doi.org/10.1002/nop2.272.
Yan P, Li F, Zhang L, et al. Prevalence of work-related musculoskeletal disorders in the nurses working in hospitals of Xinjiang Uygur Autonomous Region. Pain Res Manag. 2017; 2017:5757108. https://doi.org/10.1155/2017/5757108.
Li W. Investigation and study on the low back pain of nurses in the department of critical care medicine in a third grade hospital. Diet and Health. 2018; 5(14):15-16.
Jianjie C. Some Applied Research of Mathematical Statistics in Medicine and Other Fields. Beijing University of Civil Engineering and Architecture. 2016.
Kong WW, Liu JL, Chen SY. Work stress analysis and intervention strategies for nurses in ICU. Journal of Traditional Chinese Medicine Management. 2016;24(18):120-1. 12. Zhang WQ, Li D, Gui F. Investigation on occupational musculoskeletal injury and its influencing factors among nurses in Wuhan City. Occup and Health 2016; 32(11):1469-72.
Yang S, Lu J, Zeng J, Wang L, Li Y. Prevalence and risk factors of work-related musculoskeletal disorders among intensive care unit nurses in China. Workplace Health Saf. 2019;67(6):275-87. https://doi.org/10.1177/2165079918809107.
Chen XH, Li N. Investigation on occupational low back pain protection of ICU nurses in 3A grade hospital. Fujian Med J. 2017;39(1):149-50.
Ann Adamczyk M. Reducing intensive care unit staff musculoskeletal injuries with implementation of a safe patient handling and mobility program. Crit Care Nurs Q. 2018;41(3):264-71. https://doi.org/10.1097/CNQ.0000000000000205.
Weiner C, Kalichman L, Ribak J, Alperovitch-Najenson D. Repositioning a passive patient in bed: choosing an ergonomically advantageous assistive device. Appl Ergo. 2017;60:22-9. https://doi.org/10.1016/j.apergo.2016.10.007.
Marshall L, Villeneuve J, Grenier S. Effectiveness of a multifactorial ergonomic intervention and exercise conditioning kinesiology program for subsequent work related musculoskeletal disorder prevention. Work. 2018;61(1):81-9. https://doi.org/10.3233/WOR-182782.
Becker A, Angerer P, Mueller A. The prevention of musculoskeletal complaints: a randomized controlled trial on additional effects of a work-related psychosocial coaching intervention compared to physiotherapy alone. Int Arch Occup Environ Health. 2017;90(4):357-71. https://doi.org/10.1007/s00420-017-1202-6.
Larsen AK, Holtermann A, Mortensen OS, Punnett L, Rod MH, Jorgensen MB. Organizing workplace health literacy to reduce musculoskeletal pain and consequences. BMC Nurs. 2015;14:46. https://doi.org/10.1186/s12912-015-0096-4.
Carr LJ, Leonhard C, Tucker S, Fethke N, Benzo R, Gerr F. Total worker health intervention increases activity of sedentary workers. Am J Prev Med. 2016;50(1):9-17. https://doi.org/10.1016/j.amepre.2015.06.022.
Freimann T, Merisalu E, Paasuke M. Effects of a home-exercise therapy programme on cervical and lumbar range of motion among nurses with neck and lower back pain: a quasi-experimental study. BMC Sports Sci Med Rehabil. 2015;7:31. https://doi.org/10.1186/s13102-015-0025-6.
Ghadyani L, Tavafian SS, Kazemnejad A, Wagner J. Effectiveness of Multidisciplinary group-based intervention versus individual physiotherapy for improving chronic low back pain in nursing staff: a clinical trial with 3-and 6-month follow-up visits from Tehran, Iran. Asian Spine J. 2017;11(3):396-404. https://doi.org/10.4184/asj.2017.11.3.396.
Richardson A, McNoe B, Derrett S, Harcombe H. Interventions to prevent and reduce the impact of musculoskeletal injuries among nurses: a systematic review. Int Nurs Stud. 2018;82:58-67. https://doi.org/10.1016/j.ijnurstu.
Tullar JM, Brewer S, Amick BC, 3rd, et al. Occupational safety and health interventions to reduce musculoskeletal symptoms in the health care sector. J Occup Rehabi. 2010;20(2):199-219. https://doi.org/10.1007/s10926-010-9231-y.
Christensen JR, Bredahl TVG, Hadrevi J, Sjogaard G, Sogaard K. Background, design and conceptual model of the cluster randomized multiple-component workplace study: framed Intervention to decrease occupational muscle pain - "FRIDOM". BMC Public Health. 2016;16(1):1116. https://doi.org/10.1186/s12889-016-3758-6.
Vendittelli D, Penprase B, Pittiglio L. Musculoskeletal injury prevention for new nurses. Workplace Health Saf. 2016;64(12):573-85. https://doi.org/10.1177/2165079916654928.
Choi SH, Duffy SA. Analysis of health behavior theories for clustering of health behaviors. J Addict Nurs. 2017;28(4):203-9. https://doi.org/10.1097/JAN.0000000000000195.
Sharafkhani N, Khorsandi M, Shamsi M, Ranjbaran M. The effect of an educational intervention program on the adoption of low back pain preventive behaviors in nurses: an application of the health belief model. Global Spine J. 2016;6(1):29-34. https://doi.org/10.1055/s-0035-1555658.
Kim KM, Lee SJ. Work-related perceptions, injuries, and musculoskeletal symptoms: comparison between U.S.-educated and foreign-educated nurses. Workplace Health Saf. 2019;67(7);326-37. https://doi.org/10.1177/2165079918821699.
Jakobsen MD, Aust B, Dyreborg J, Kines P, Illum MB, Andersen LL. Participatory organizational intervention for improved use of assistive devices for patient transfer: study protocol for a single-blinded cluster randomized controlled trial. BMC Musculoskelet Disord. 2016;17(1):501. https://doi.org/10.1186/s12891-016-1339-6.
Stevens ML, Boyle E, Hartvigsen J, et al. Mechanisms for reducing low back pain: a mediation analysis of a multifaceted intervention in workers in elderly care. Int Arch Occup Environ Health. 2019;92(1):49-58. https://doi.org/10.1007/s00420-018-1350-3.
Geiger-Brown J, Lipscomb J. The health care work environment and adverse health and safety consequences for nurses. Ann Rev Nurs Res. 2010;28:191-231. https://doi.org/10.1891/0739-6686.28.191.
QiuHong C. Construction of a training system for new nurses. Chinese Journal of Nursing Education. 2019;16(10):775-8.
Geng J. Analysis of the effect of ICU training for specialist nurses. Today Nursing. 2016(12):160-2.
Yang Z, Qian R, Xie H. Application of risk perception theory in health field. Journal of Modern Medicine & Health. 2017, 33(8):1169-72.
Prochaska JO, Velicer WF. The transtheoretical model of health behavior change. Am Journal Health Promot. 1997;12(1):38-48. https://doi.org/10.4278/0890-1171-12.1.38.
Golubovich J, Chang CH, Eatough EM. Safety climate, hardiness, and musculoskeletal complaints: a mediated moderation model. Appl Ergon. 2014;45(3):757-66. https://doi.org/10.1016/j.apergo.2013.10.008.
Fang YX, Li SY, Zhang YN, Zhang P, Wu H, Wang DH. Test-retest reliability of Nordic Musculoskeletal Questionnairein nurses. Zhonghua Lao Dong Wei Sheng Zhi Ye Bing Za Zhi. 2013;31(10):753-8.
Lee SJ, Faucett J, Gillen M, Krause N, Landry L. Risk perception of musculoskeletal injury among critical care nurses. Nurs Res. 2013;62(1):36-44. https://doi.org/10.1097/NNR.0b013e31827334d6.
Xu N, Zhang PL, Wang BQ. Reliability and vaIIdity of Chines eversion of the gershon hospital safety climate scale. Chin Nurs Manag. 2013;13(3):22-5.
Hartvigsen J, Lauritzen S, Lings S, Lauritzen T. Intensive education combined with low tech ergonomic intervention does not prevent low back pain in nurses. Occup Environ Med. 2005;62(1):13-7. https://doi.org/10.1136/oem.2003.010843.
Ching SSY, Szeto G, Lai GKB, Lai XB, Chan YT, Cheung K. Exploring the synergic effects of nursing home work on work-related musculoskeletal disorders among nursing assistants. Workplace Health Saf. 2018;66(3):129-35. https://doi.org/10.1177/2165079917717497.
Yan P, Yang Y, Zhang L, et al. Correlation analysis between work-related musculoskeletal disorders and the nursing practice environment, quality of life, and social support in the nursing professionals. Medicine. 2018;97(9):e0026. https://doi.org/10.1097/MD.0000000000010026.
Ratzon NZ, Bar-Niv NA, Froom P. The effect of a structured personalized ergonomic intervention program for hospital nurses with reported musculoskeletal pain: an assigned randomized control trial. Work. 2016;54(2):367-77. https://doi.org/10.3233/WOR-162340.
Carugno M, Pesatori AC, Ferrario MM, et al. Physical and psychosocial risk factors for musculoskeletal disorders in Brazilian and Italian nurses. Cad Saude Publica. 2012;28(9):1632-142. https://doi.org/10.1590/s0102-311x2012000900003.
Sadeghian F, Hosseinzadeh S, Aliyari R. Do psychological factors increase the risk for low back pain among nurses? A comparing according to cross-sectional and prospective analysis. Saf Health Work. 2014;5(1):13-6. https://doi.org/10.1016/j.shaw.2013.11.004.
Li Furu, Yun Z. Intervention result and self-protection status survey of occupational musculoskeletal injury for nurses. China Medical Herald. 2018;15(25):178-81.
Lee EW, Fok JP, Lam AT, Law RK, Szeto GP, Li PP. The application of participatory ergonomics in a healthcare setting in Hong Kong. Work. 2014;48(4):511-19. https://doi.org/10.3233/WOR-141918.
Chanchai W, Songkham W, Ketsomporn P, Sappakitchanchai P, Siriwong W, Robson MG. The Impact of an ergonomics intervention on psychosocial factors and musculoskeletal symptoms among thai hospital orderlies. In J Environ Res Public Health. 2016;13(5):464. https://doi.org/10.3390/ijerph13050464.
Friman M, Huck J, Olsson L. Transtheoretical model of change during travel behavior interventions: an integrative review. Int J Environ Res Public Health. 2017;14(6):581. https://doi.org/10.3390/ijerph14060581.
Kindblom-Rising K, Wahlstrom R, Nilsson-Wikmar L, Buer N. Nursing staff's movement awareness, attitudes and reported behaviour in patient transfer before and after an educational intervention. Appl Ergon. 2011;42(3):455-63. https://doi.org/10.1016/j.apergo.2010.09.003.
Theou O, Soon Z, Filek S, et al. Changing the sheets: a new system to reduce strain during patient repositioning. Nurs Res. 2011;60(5):302-8. https://doi.org/10.1097/NNR.0b013e318225b8aa.
Bartnik LM, Rice MS. Comparison of caregiver forces required for sliding a patient up in bed using an array of slide sheets. Workplace Health Saf. 2013;61(9):393-400. https://doi.org/10.1177/216507991306100904.
Kim SL, Lee JE. Development of an intervention to prevent work-related musculoskeletal disorders among hospital nurses based on the participatory approach. Appl Ergon. 2010;41(3):454-60. https://doi.org/10.1016/j.apergo.2009.09.007.

Table 1

Demographic characteristics of intensive care unit nurses (N=190)
Variables	Control group	Intervention group	t/c²-value	p-value
Variables	Mean ± SD ^a or n (%)	Mean ± SD ^a or n (%)	t/c²-value	p-value
Age	28.83±4.25	28.86±4.13	0.055	0.956
Sex Male female	19 70	18 83	0.585	0.333
BMI <18.5 18.5—23.9 24.0—27.9 ≥28	14 58 15 2	16 65 19 1	0.580	0.901
Marital Status Single Married	36 53	43 58	0.088	0.771
ICU employment 1—2 years 3—5 years 5—10 years >10 years	10 32 28 19	14 26 43 18	3.316	0.191
Job title Nurse Senior nurse Supervisor nurse	31 39 19	28 47 26	2.320	0.314
Education Junior college ^b Bachelor Master/Doctoral	4 71 4	17 73 11	0.828	0.008

^aSD=Standard deviation. ^b Junior college refers to a full-time nurse training in a vocational and technical school.

Table 2

Parameter estimation of the generalized estimation equation for the reported rate of WRMDs in the past 7 days.
Variables	Single factor						Multiple-factor
Variables	B	SE	OR	Upper	Lower	p-value	B	SE	OR	Lower	Upper	p-value
Age	0.041	0.033	1.042	0.976	1.112	0.220
Sex Male female	0.842	0.288	2.322 1	1.320	4.083	0.003	0.902	0.295	2.465	1.383	4.396	0.002
BMI <18.5 18.5—23.9 24.0—27.9 ≥28	-1.124 -1362 -0.058	0.968 0.931 0.974	0.325 0.256 0.347 1	0.049 0.041 0.051	2.165 1.590 2.344	0.245 0.144 0.278
Marital Status Single Married	0.253	0.253	1.288 1	0.784	2.115	0.318
ICU employment 1—2 years 3—5 years 5—10 years >10 years	-0.873 0.424 0.028	0.412 0.373 0.348	0.418 1.528 1.028 1	0.186 0.736 0.520	0.936 3.173 2.032	0.034 0.255 0.937
Job title Nurse Senior nurse Supervisor nurse	-0.272 0.103	0.325 0.313	0.762 1.109 1	0.403 0.600	1.441 2.048	0.403 0.741
Education Junior college Bachelor Master/Doctoral	-0.710 -0.268	0.628 0.542	0.492 0.765 1	0.144 0.265	1.683 2.212	0.258 0.621
Group Group=0(Control group) Group=1 (Intervention group)							-0.670	0.325	0.512 1	0.217	0.946	0.038
Time Time=0 (Baseline) Time=1 (3 months) Time= 2 (6 months)							0.317 0.121	0.316 0.191	1.374 1.129 1	0.740 0.766	2.551 1.642	0.315 0.526
Grouptime [Group=0][Time=0] [Group=0][Time=1] [Group=0][Time=2] [Group=1][Time=0] [Group=1][Time=1] [Group=1]*[Time=2]							0.227 -0.036	0.406 0.234	1.225 0.965 1 1 1 1	0.566 0.610	2.782 1.526	0.578 0.878

Table 3

Parameter estimation of the generalized estimation equation for the risk perception of WRMDs.
Variables	Single factor						Multiple-factor
Variables	B	SE	OR	Upper	lower	p-value	B	SE	OR	lower	Upper	p-value
Age	-0.010	0.011	0.990	0.970	1.011	0.347
Sex Male female	-0.013	0.088	0.987 1	0.831	1.172	0.879
BMI <18.5 18.5—23.9 24.0—27.9 ≥28	-0.061 -0.034 -0.044	0.136 0.122 0.137	0.941 0.966 0.957 1	0.721 0.760 0.730	1.227 1.228 1.255	0.652 0.780 0.752
Marital Status Single Married	0.118	0.069	1.125 1	0.983	1.287	0.087
ICU employment 1—2 years 3—5 years 5—10 years >10 years	0.007 0.028 -0.057	0.137 0.095 0.101	1.007 1.028 0.945 1	0.770 0.853 0.755	1.317 1.240 1.151	0.960 0.769 0.572
Job title Nurse Senior nurse Supervisor nurse	0.185 0.074	0.096 0.091	1.204 1.076 1	0.996 0.901	1.454 1.286	0.054 0.416
Education Junior college Bachelor Master/Doctoral	0.010 0.133	0.152 0.096	1.010 1.143 1	0.750 0.946	1.362 1.380	0.946 0.167
Group Group=0 (Control group) Group=1 (Intervention group)							-0.660	0.100	0.517 1	0.424	0.629	<0.001
Time Time=0 (Baseline) Time=1 (3 months) Time= 2 (6 months)							-0.819 0.073	0.087 0.078	0.441 1.076 1	0.372 0.924	0.523 1.252	<0.001 0.346
Grouptime [Group=0][Time=0] [Group=0][Time=1] [Group=0][Time=2] [Group=1][Time=0] [Group=1][Time=1] [Group=1]*[Time=2]							0.554 0.226	0.132 0.117	1.740 1.305 1 1 1 1	1.345 1.038	2.252 1.640	<0.001 0.023

Table 4

Parameter estimation of the generalized estimation equation for the health behavior applying of WRMDs.
Variables	Single factor						Multiple-factor
Variables	B	SE	OR	Upper	lower	p-value	B	SE	OR	lower	Upper	p-value
Age	0.008	0.089	1.008	0.845	1.202	0.928
Sex Male female	-1.170	0.887	0.310 1	0.055	1.768	0.187
BMI <18.5 18.5—23.9 24.0—27.9 ≥28	2.933 1.347 2.127	1.377 1.056 1.275	8.790 3.845 5.393 1	1.276 0.485 0.689	36.639 13.463 28.236	0.033 0.202 0.095
Marital Status Single Married	1.137	0.741	3.116 1	0.729	13.323	0.125
ICU employment 1—2 years 3—5 years 5—10 years >10 years	-0.262 0.360 -1.110	1.218 1.015 0.973	0.769 1.433 0.329 1	0.071 0.196 0.049	8.367 10.470 2.218	0.829 0.723 0.254
Job title Nurse Senior nurse Supervisor nurse	1.202 -0.258	0.953 0.921	3.326 0.773 1	0.514 0.125	21.514 4.774	0.207 0.781
Education Junior college Bachelor Master/Doctoral	-0.832 0.568	1.687 1.428	0.435 1.764	0.016 0.107	11.867 29.002	0.622 0.691
Group Group=0 (Control group) Group=1 (Intervention group)							-5.387	0.986	1.025 1	0.011	0.132	<0.001
Time Time=0 (Baseline) Time=1 (3 months) Time= 2 (6 months)							-9.112 0.225	0.824 0.740	0.015 1.252 1	2.149 0.294	0.011 5.339	<0.001 0.761
Grouptime [Group=0][Time=0] [Group=0][Time=1] [Group=0][Time=2] [Group=1][Time=0] [Group=1][Time=1] [Group=1]*[Time=2]							6.370 1.340	1.242 1.233	23.932 3.818 1 1 1 1	21.197 0.341	46.157 42.757	<0.001 0.277

Table 5

Parameter estimation of the generalized estimation equation for the perception of a safe working environment of WRMDs.
Variables	Single factor						Multiple-factor
Variables	B	SE	OR	Upper	lower	p-value	B	SE	OR	lower	Upper	p-value
Age	0.352	0.177	1.422	1.004	2.014	0.047	0.084	0.360	1.087	0.537	2.200	0.816
Sex Male femal	2.629	1.795 1	13.853	0.410	27.541	0.143
BMI <18.5 18.5—23.9 24.0—27.9 ≥28	-6.089 -4.745 -4.062	3.206 2.915 3.133 1	0.002 0.009 0.017	4.233 2.869 3.710	1.215 2.634 7.986	0.058 0.104 0.195
Marital Status Single Married	-1.323	1.442	0.266 1	0.016	4.496	0.359
ICU employment 1—2 years 3—5 years 5—10 years >10 years	-2.099 -5.063 -0.243	2.321 2.002 1.699	0.016 0.784 1	0.005 0.001 0.028	11.583 0.320 21.904	0.366 0.011 0.886	-1.128 -4.365 0.078	4.395 3.493 2.357	0.278 0.013 1.081	5.037 1.352 0.011	53.207 11.950 29.596	0.771 0.211 0.974
Job title Nurse Senior nurse Supervisor nurse	-3.450 0.001	1.855 1.645	0.032 0.998	0.001 0.040	1.203 25.162	0.063 0.998
Education Junior college Bachelor Master/Doctoral	2.813 0.036	2.975 1.853	0.060 1.036	0.001 0.027	20.436 39.181	0.344 0.985
Group Group=0 (Control group) Group=1 (Intervention group)							1.534	2.192	1.637 1	1.063	40.371	0.024
Time Time=0 (Baseline) Time=1 (3 months) Time= 2 (6 months)							2.685 -0.539	2.027 1.499	14.667 0.583 1	0.276 0.031	49.842 11.001	0.185 0.719
Grouptime [Group=0][Time=0] [Group=0][Time=1] [Group=0][Time=2] [Group=1][Time=0] [Group=1][Time=1] [Group=1]*[Time=2]							-1.507 -0.926	2.430 1.993 0.222 0.396	0.222 0.396 1 1 1 1	0.002 0.008	25.915 19.679	0.535 0.642

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Effectiveness of a multidimensional intervention program in improving occupational musculoskeletal disorders among intensive care units nurses: a cluster controlled trial with follow-up at 3 and 6 months

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Abstract

Figures

Background

Methods

Study design

Setting

Recruitment of ICUs

Recruitment of participants

Eligibility criteria of participants

Intervention

Improvement of risk perception of WRMD

Health behavior training

Providing a safe work environment

Routine specialist training in WRMDs

Measurement

Primary outcome

Report rate of WRMDs in the past 7 days

Secondary outcomes

Risk perception

Health behavior applying

Perception of a safe working environment

Data analysis

Results

Study sample

Baseline data

Intervention effects

Discussion

Conclusion

Abbreviations

Declarations

Ethics approval and consent to participate

Consent for publication

Availability of data and materials

Competing interests

Funding

Authors’ contributions

Acknowledgements

References

Tables

Status:

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