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Associations of Psychosocial and Individual Factors with Three Different Categories of Back Disorder among Nursing Staff

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Associations of Psychosocial and Individual Factors with Three Different Categories of Back Disorder among Nursing Staff
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   J Occup Health 2004; 46: 100–108 Journal of Occupational Health  Associations of Psychosocial and Individual Factors with ThreeDifferent Categories of Back Disorder among Nursing Staff  Francesco S. V IOLANTE 1 , Marina F IORI 2 , Cristiana F IORENTINI 3 , Alessandro R ISI 3 ,Giacomo G ARAGNANI 2 , Roberta B ONFIGLIOLI 2  and Stefano M ATTIOLI 2 1 Alma Mater Studiorum—University of Bologna, Occupational Medicine Unit, Sant’Orsola-Malpighi Hospital, 2 Occupational Medicine Unit, Sant’Orsola-Malpighi Hospital and 3 School of Occupational Medicine, Universityof Bologna, Italy Abstract: Associations of Psychosocial andIndividual Factors with Three Different Categoriesof Back Disorder among Nursing Staff: FrancescoS. V IOLANTE , et al  . Alma Mater Studiorum  —Universityof Bologna, Occupational Medicine Unit, Sant’Orsola-Malpighi Hospital, Italy—Although back disorders area major occupational problem for nursing staff, fewstudies distinguish different types. By means of astructured questionnaire, we performed a cross-sectional study on the prevalence of diagnosed lumbardisc hernia, chronic low-back pain (LBP) (at least 90 din the preceding 12 months) and acute LBP (intensepain for at least 1 d) with respect to physical, individualand psychosocial factors among female nurses(n=587), nursing aides (n=228) and head-nurses (n=43)working in a university hospital (95% of the femaleworkforce). Almost all respondents reported knownhigh-risk occupational activities. Overall prevalenceof reported back disorders was 44% (acute LBP 19%,chronic LBP 17%, lumbar hernia 8%). On multinomiallogistic regression analysis, scoliosis and commonlystress-related psychosomatic symptoms wereassociated with all three types of back disorder; trauma/ fractures of the spine, pelvis and/or legs and a globalwork-environment/job-satisfaction score with acuteLBP; increasing age with lumbar disc hernia. Whileconfirming the relevance of considering differentdefinitions of back disorder, our data indicate items forinvestigation in cohort studies. These include:identification of specific risk factors for lumbar hernia;avoidance of possible work-environment risk factorssuch as hurried execution of different tasks at the same  Received Jan 21, 2003; Accepted Nov 17, 2003Correspondence to: F. S. Violante, Alma Mater Studiorum— Università di Bologna, Unità Operativa di Medicina del Lavoro, Policlinico Sant’Orsola Malpighi, Via Pelagio Palagi 9, 40138 Bologna, Italy(e-mail: francesco.violante@unibo.it) time; and influence on job suitability of underlying spinalpathologies such as scoliosis. (J Occup Health 2004; 46: 100–108) Key words:  Low-back pain, Lumbar hernia, Nursingstaff, Biomechanical overload, Scoliosis,Psychosomatic symptoms, Psychosocial factors Work-related musculoskeletal disorders constitute amajor problem among nursing staff  1–6) , who often have ahigher prevalence of lower back pain (LBP) thanindustrial workers 7–9) . As society ages, the increasingamount of physical handling of elderly people raises thepossibility of a higher prevalence of serious work-relatedmusculoskeletal disorders among nursing staff  10) .Epidemiological studies show that work-related riskfactors, such as lifting, twisting, bending, exposure towhole body vibration, and prolonged postures playprominent roles 11–13) . Several studies have indicated thatpsychological and psychosocial factors can also affectthe risk of LBP 14–17) . On the other hand, the availabledata on individual risk factors are inconsistent, and thereis no clear evidence of any specific association 18) . Suchinconsistencies between studies could be due either toweak associations, or to the fact that “LBP” is a vagueterm (lacking consensual definition) which can conceala multitude of underlying conditions 19) .Few studies have taken into account different categoriesof LBP 20–22) . We performed a cross-sectional study toinvestigate possible associations of three differentcategories of back disorder (chronic or acute LBP anddiagnosed lumbar disc hernia) with a series of physical(work-related), individual and psychosocial risk factorsamong a relatively homogeneous population of femalehospital nursing staff exposed to specific risk factors.  101  Francesco S. V   IOLANTE , et al.: Risk of Different Back Disorders in Nursing Staff  Methods Study population This cross-sectional study was carried out in a largeuniversity hospital in September 1997. Questionnaireswere distributed to the entire female nursing staff regularly employed by the hospital (n=901), grouped byoccupational status into nurses, nursing aides and head-nurses. The purpose and contents of the questionnairewere explained to the subjects beforehand. Respondentsall provided their consent to participate in the study. Questionnaire All subjects filled in at their workplace a structuredquestionnaire designed to assess possible physical (work-related), individual, and psychosocial risk factors for threedifferent definitions of back disorder. Subjects wererequired to specify the presence in the preceding 12months of episodes of 1) acute LBP, defined as intensepain (not due to menses) for at least one day; 2) chronicLBP, daily pain for at least 90 days; 3) instrumentallydiagnosed herniation of a lumbar disc. Subjects specifiedthe following individual characteristics: age; height/ weight (to calculate body mass index, BMI); maritalstatus; motherhood; smoking; sporting activity (regular since childhood and currently for at least 3 h a week);diagnosis of scoliosis; presence/absence of trauma or fractures of the spine, pelvis and/or legs; other diagnosedspine pathologies; kidney stones; diagnosed osteoporosis.Regarding occupational factors, responders specifiedduration of employment in the present ward, cumulativeduration of professional career in nursing, and presence/ absence (in current/previous nursing duties) of knownphysical work-related risk factors for LBP (i.e. fixedpostures for over 4 hours a day and/or manual handlingof patients or materials) 23, 24) .Three groups of psychosocial items (commonly stress-related psychosomatic symptoms; depression-relatedtendencies; external/internal coping strategies) werescored by frequency ratings (1, “never”; 2, “occasionally”;3, “often”; 4, “always”). A further psychosocial itemsrelated to work-environment/job-satisfaction wasformulated according to the “demand-control model”introduced by Karasek 25)  and developed by Karasek andTheorell 26) , which assumes that the presence of adverseconsequences if high job demands are associated with alack of the possibility to control and influence job-relateddecisions; these items were scored by the interviewees’degree of agreement (1, “not at all”; 2, “not a lot”; 3,“fairly”; 4, “completely”). Statistical Analysis Only one main category of back disorder was attributedto any individual, with lumbar disc hernia takingprecedence over chronic LBP, which in turn tookprecedence over acute LBP. A skewness-kurtosis testwas used to evaluate normal distribution of values 27) . Incases of normal distribution, continuous variables weretested with Student’s t test or ANOVA; otherwise, two-sample tests were performed with the Wilcoxon rank-sum test, and the Kruskall-Wallis test was used insteadof ANOVA. The Scheffé multiple comparison test wasused to locate significant differences. Categoricalvariables were assessed with the χ 2  test or Fisher’s exacttest, as appropriate.Multinomial (polytomous) logistic regression 28)  wasused to assess relationships among potential risk factorsand each of the three main categories of back disorder described above and the ‘no symptoms’ referencecategory. Age was included in each logistic regressionmodel (because of its known influence on LBP) 29) ,whereas mean cumulative career and occupational statuswere always omitted to avoid multicollinearity due totheir correlations with age. Similarly, marital status wasalso omitted from the models because of its closeassociation with motherhood. Interaction effect variableswere not included.A binomial logistic regression analysis was performedto assess the factors predictive for a separately definedcategory of ‘ chronic LBP with/without lumbar dischernia .’ Intercooled Stata 7.0 software (StataCorporation, Texas, TX, USA) was used for all analysis,with significance being set at  p <0.05. Results Questionnaires were returned by 858 subjects (95.2% Table 1. Prevalence of three categories of back disorder among a population of female hospital nursesNNo symptomsAcute LBPChronic LBPLumbar disk herniaN%N%N%N%Nurses58734859.39616.410117.2427.2Nurses aids22811751.35524.13816.7187.9Head nurses431944.21023.3920.9511.6Total85848456.416118.814817.3657.6  p =0.113 at χ 2  test  102  J Occup Health, Vol. 46, 2004 of the total female workforce), including 587 nurses, 228nursing aides and 43 head-nurses. Current execution of tasks at high-risk for LBP were reported by 791 (94.6%)respondents (past execution of such tasks elsewhere wasalso reported by 294 respondents).The overall prevalence of back disorder in thepreceding 12 months was 43.6% (n=374). Table 1 reportsthe prevalences of the three main categories of backdisorder among the three groups of workers; thedifferences did not reach significance in an χ 2  test. Itshould be noted that only 161 of the 257 workers whoreported acute pain were actually classified under ‘acuteLBP’ (effectively referring to cases of pain presenting only  in an acute context), whereas the remaining 62 and34 were included in the ‘chronic LBP’ and ‘lumbar dischernia’ categories respectively. Furthermore, only 148of the 173 workers who reported chronic pain wereactually classified under ‘chronic LBP’, the remaining25 being included in the ‘lumbar disc hernia’ category. Univariate analysis Univariate analysis of occupational, individual, andpsychosocial factors are reported in Tables 2 and 3,respectively. Length of service (mean cumulative career)was significantly associated with prevalence of lumbar disc hernia (Table 2). Apart from a higher prevalence of scoliosis among head nurses, no significant difference inrisk-factor distribution was apparent among the three jobtitles (Table 2). As regards individual factors, highlysignificant associations with at least one category of backdisorder were found for scoliosis, trauma/fracture of thespine, pelvis or legs, increasing age, and other diagnosed B. Individual factors with respect to three categories of back disorder No symptomsAcute LBPChronic LBPLumbar disk hernia  p  valuen/N%n/N%n/N%n/N%Motherhood230/48247.779/16049.487/14759.238/6459.40.046 b Scoliosis52/46911.137/15923.336/14325.216/6225.80.000 b Smoking (ever)180/48437.264/16139.849/14833.125/6538.50.671 b Trauma/fractures of spine, pelvis and/or legs100/48420.761/16137.945/14830.427/6541.50.000 b Other diagnosed spine3/4840.65/1613.16/1484.13/654.60.010 b  pathologiesSport59/48412.216/1619.911/1487.46/659.20.389 b MeanSDMeanSDMeanSDMeanSDAge (yr)35.08.53517.836.68.440.18.40.000 a BMI (kg/m 2 )23.23.923.43.923.44.623.43.80.735 a Mean cumulative career (yr)10.17.610.26.911.37.414.18.40.001 aa Kruskall-Wallis test, b χ 2  test Table 2. Distribution of individual risk factors: A. Individual factors with respect to three job titlesNursesNursing aidsHead nursesOverall  p  valuen/N%n/N%n/N%n/N%Motherhood300/58251.6119/22852.215/4334.9434/85350.90.097 b Scoliosis86/56915.142/22218.913/4230.0141/83316.90.020 b Smoking (ever)220/58737.585/22837.313/4330.2318/85837.10.635 b Trauma/fractures of spine, pelvis and/or legs158/58726.962/22827.213/4330.2233/85827.20.895 b Other diagnosed spine13/5872.22/2280.92/434.717/8582.00.205 b  pathologiesSport58/5879.926/22811.48/4318.692/85810.70.189 b MeanSDMeanSDMeanSDMeanSDAge (yr)35.88.535.88.533.87.335.78.50.395 a BMI (kg/m 2 )23.44.12314.122.83.423.34.00.698 a Mean cumulative career (yr)10.77.510.77.79.58.110.67.60.461 a  103  Francesco S. V   IOLANTE , et al.: Risk of Different Back Disorders in Nursing Staff  spine pathologies; a significant association was recordedfor motherhood (Table 2).Results regarding psychosocial factors are shown inTable 3. In the Kruskal-Wallis test, nursing staff with noback disorder turned out to have significantly lower globalscores for ‘commonly stress-related psychosomaticsymptoms’, ‘depression-related tendencies’ and ‘work-environment/job-satisfaction’ but not for ‘internal/ external coping strategies’. (It is noteworthy that eachof the items regarding ‘commonly stress-relatedpsychosomatic symptoms’ and ‘depression-relatedtendencies’ had significantly higher scores with respectto the ‘no symptoms’ category.) Among the various“work-environment/job-satisfaction” items, higher scoreswith respect to the ‘no symptoms’ category were recordedfor “having to do many things hurriedly at the same time”,“wanting to go straight to bed on returning home” and“gratification from responsibilities”. Results of themultiple comparison test (used to locate differencesbetween categories) are also reported in Table 3.  Multivariate analysis In a primary multinomial logistic regression analysismodel (Table 4), we included individual factors thatreached significance on univariate analysis (i.e. scoliosis,trauma/fractures, age, other diagnosed spine pathologies),variables commonly suspected to be of relevance indetermining or reducing back disorders (BMI, smoking,sporting activity), and the global scores of the mainpsychological/psychosocial groupings (‘stress-relatedpsychosomatic symptoms’, ‘depression-relatedtendencies’, ‘external/internal coping strategies’, and‘work-environment/job-satisfaction’). For both the acuteLBP and chronic LBP subgroups, relationships emergedfor the presence of scoliosis, and the global ‘stress-relatedpsychosomatic symptom’ score. The presence of trauma/ fractures (of the spine, pelvis and/or legs) was significantfor acute LBP. In the lumbar disc hernia subgroup, theonly significant relationships were with scoliosis, ‘stress-related psychosomatic symptoms’ (global score), andincreasing age.We then inserted, one by one, each of the single Table 3. Distribution of mean response scores to questions regarding psychosocial items No symptomsAcute LBPChronic LBPLumbar disk herniaMeanMedianMeanMedianMeanMedianMeanMedian(SD)(iqr)(SD)(iqr)(SD)(iqr)(SD)(iqr)  p  value c Commonly stress-related13.0(3.2)13(4)14.8(3.0) a 15(4)15.3(3.3) a 15(4)14.4(3.8) a 15(5)0.000 psychosomatic symptoms  Problem getting to sleep or    remaining asleep 2.0(0.8)2(1)2.2(0.8) a 2(1)2.2(1.0)2(2)2.2(0.9)2(2)0.000  Heartburn or gastric pains 2.0(0.8)2(2)2.3(0.8) a 2(1)2.3(0.9) a 2(1)2.3(0.9)2(2)0.000  Belly pains or sensation of    bloatedness 2.3(0.8)2(1)2.6(0.8) a 3(1)2.7(0.9) a 3(1)2.4(1.0)2(1)0.000  Headache or nauseas 2.2(0.8)2(1)2.4(0.7) a 2(1)2.4(0.8) a 3(1)2.3(0.8)2(1)0.000  Diffuse body pain 1.8(0.8)2(1)2.3(0.7) a 2(1)2.5(0.8) a 3(1)2.4(0.9) a 3(1)0.000  Heaviness of the limbs 2.7(0.9)3(1)3.0(0.8) a 3(1)3.2(0.8) a 3(1)2.9(0.9)3(0)0.000Depression-related tendencies7.9(2.3)8(3)8.5(2.3) a 8(3)8.8(2.3) a 8(4)8.1(2.3)8(2)0.000  Lack of interest in doing anything 2.1(0.7)2(0)2.2(0.6)2(0)2.4(0.6) a 2(1)2.1(0.8) b 2(1)0.000  Irritability 2.2(0.7)2(0)2.2(0.7)2(1)2.4(0.7) a 2(1)2.2(0.8)2(1)0.000  Inability to tolerate other people 1.9(0.7)2(1)2.1(0.7) a 2(0)2.1(0.8)a2(1)2.0(0.7)2(0)0.001  Feeling overwhelmed by events 1.8(0.8)2(1)2.0(0.9)2(2)2.1(0.8) a 2(2)2.0(0.8)2(1)0.013External/internal coping strategies11.7(1.7)12(2)11.6(17)12(2)11.3(1.8)12(2)11.8(1.7)12(2)0.141Work environment/Job-satisfaction24.4(3.7)24(5)25.5(3.4) a 26(5)25.3(3.6)25(5)25.2(4.0) a 25(5)0.001  Having to do many things hurriedlyat the same time 3.3(0.8)3(1)3.4(0.8)4(1)3.4(0.8)4(1)3.6(0.6) a 4(1)0.006 Gratification from responsibility 1.7(0.8)2(1)1.8(0.8)2(1)1.9(0.9)2(1)1.7(0.7)2(1)0.057 Wanting to go straight to bed onreturning home 3.3(0.8)3(1)3.5(0.8) a 4(1)3.6(0.6) a 4(1)3.4(0.9)4(1)0.000iqr=Inter-quartile range, Scores: 1, “not at all”, 2, “not a lot”, 3, “fairly”, 4, “completely” a : Significantly different with respect to ‘no symptoms’ at multiple comparison (Scheffé test), b : Significantly different with respect to ‘chronicLBP’ at multiple comparison (Scheffé test), c : Kruskall-Wallis test  104  J Occup Health, Vol. 46, 2004 Table 4. Primary multinomial logistic regression analysis modelAcute LBPChronic LBPLumbar disk herniaConditional  p 95% CIConditional  p 95% CIConditional  p 95% CI OROR ORBMI1.040.1850.98–1.091.010.6680.98–1.051.000.9430.91–1.09Age1.010.5590.98–1.041.010.3550.98–1.05 1.080.0001.04–1.13 Motherhood0.980.9480.60–1.611.650.0550.99–2.761.090.8150.52–2.31Smoking1.060.8020.69–1.620.700.1330.44–1.110.950.8790.49–1.85Scoliosis  2.600.0011.51–4.472.670.0011.53–4.673.270.0021.55–6.88 Trauma/fractures of spine, pelvis and/or legs  2.170.0011.38–3.39 1.500.1020.92–2.431.530.2280.77–3.05Other diagnosed spine pathologies1.930.3960.42–8.801.240.8010.23–6.601.760.5600.26–11.80Sport0.850.6430.43–1.690.830.6260.38–1.771.090.8750.38–3.08Work environment /Job satisfaction1.060.0820.99–1.141.020.4890.95–1.101.050.3250.95–1.16Commonly stress-related psychosomatic symptoms 1.160.0001.07–1.251.210.0001.12–1.321.220.0011.09–1.37  Depression-related tendencies0.990.9190.89–1.111.040.4470.93–1.170.920.3160.77–1.09External/internal coping strategies1.030.6250.91–1.170.930.2440.82–1.051.120.2410.92–1.37Results reported for each individual item are calculated with respect to the reference category of workers with “no symptoms”.OR=odds ratio. Table 5. Results of separate multinomial logistic regression analysis of psychosocial items inserted (singly) into modelscontaining individual factorsAcute LBPChronic LBPLumbar disk herniaConditional  p 95% CIConditional  p 95% CIConditional  p 95% CIORORORCommonly stress-related psychosomatic symptoms  Diffuse body pain1.630.0011.22–2.182.140.0001.56–2.932.720.0001.74–4.26  Depression-related tendencies  Irritability 0.940.7720.65–1.381.480.0570.99–2.221.450.2040.82–2.57  Inability to tolerate other people1.520.0301.04–2.21 1.190.3870.80–1.761.030.9300.58–1.82External/internal coping strategies Seeking advice 0.740.0620.54–1.010.850.3460.61–1.190.980.9200.61–1.57  Ignoring problems 1.250.1780.90–1.740.920.6300.66–1.28 1.880.0251.08–3.26  Work environment/Job satisfaction  Having to do many things hurriedly at the same time 1.190.2440.89–1.591.150.3530.86–1.53 1.870.0221.10–3.21Gratification from responsibility 1.110.5080.82–1.501.320.0640.98–1.791.190.4510.75–1.90 Wanting to go straight to bed on   returning home1.370.0361.02–1.841.520.0091.11–2.07  1.240.3230.81–1.91Individual factors inserted in the model as confounders were: BMI, Age, Motherhood, Smoking, Scoliosis, Trauma/fractures of spine, pelvis and/or legs, Other diagnosed spine pathologies, Sport Scores:1, “not at all”, 2, “not a lot”, 3, “fairly”, 4, “completely”.OR=odds ratio.
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