Golabadi M, et al.

PSYCHOSOCIAL STRAIN AND BACK SYMPTOMS IN NURSES

Arh Hig Rada Toksikol 2013;64:505-512 505

DOI: 10.2478/10004-1254-64-2013-2366
Scientific paper

EFFECTS OF PSYCHOSOCIAL STRAIN ON BACK

SYMPTOMS IN TEHRAN GENERAL HOSPITAL
NURSING PERSONNEL

Majid GOLABADI1, Mirsaeed ATTARCHI2, Saeed RAEISI2, and Mohamad NAMVAR2

Vice Chancellery for Health, Isfahan University of Medical Sciences, Isfahan1, Department of Occupational Medicine,
Tehran University of Medical Sciences, Tehran2, Iran

Received in May 2013

Cross Checked in May 2013
Accepted in November 2013

Nursing is a stressful and highly demanding job. The aim of this study was to investigate the association
between psychosocial job strain and the prevalence of back symptoms in nursing personnel using the
demand-control model. In a cross-sectional study, 545 nursing professionals answered to a self-administered
questionnaire on demography, job content, and lower and upper back symptoms (LBS and UBS,
respectively). Based on their answers, the participants were grouped as follows: low strain, high strain,
active job, and passive job. The groups were compared in regard to the prevalence of LBS and UBS
(totalling 58.5 % and 47.9 %, respectively) over the past 12 months. We found no association between job
control and back symptoms, but participants with high psychosocial job demands showed greater risk of
LBS (OR=1.57 and p=0.014) and UBS (OR=1.73 and p=0.005) than those with low job demands. LBS
in the low strain, high strain, and active job groups was more prevalent than in the passive group (OR=1.64,
OR=2.49 and OR=1.90, respectively; p≤0.05). In addition, the high strain group showed greater prevalence
of UBS than the passive group (OR=1.82 and p=0.019). Our study suggests that psychosocial job strain,
high psychosocial demands in particular, may be associated with greater prevalence of back symptoms in
nursing personnel. Our findings may help to design preventive measures that would lower the prevalence
of musculoskeletal disorders in this profession.

KEY WORDS: lower back pain, musculoskeletal system, nurses, stress, upper back pain

Musculoskeletal disorders (MSDs) are among the With a prevalence of 30 % to 60 %, low back disorders
most common complaints among factory workers (1, (LBD) are the most frequent MSDs among nurses (6).
2). The United States and Canada spend 3.1 % and About 30 % of all LBDs are work-related (8),
4.2 %, respectively for indirect costs of MSDs. including psychosocial factors such as job strain (9-
Annually, billions of dollars are spent on diagnostic 13).
and therapeutic procedures related to MSDs (3, 4). In his demand-control model, Karasek (14) defines
According to Caruso and Waters (5), musculoskeletal job strain as a combination of high psychological job
disorders are also a major cause of morbidity among demands and low job control at work. This model has
healthcare workers. Trinkoff et al. (6) suggest that extensively been used to assess psychosocial job
MSDs may be associated with increased nurse hazard in investigations of various work-related health
turnover. Owen (7) showed that 20 % of nurses had outcomes. The underlying principle is that work-
changed their jobs at least once because of an MSD. related stress, measured by levels of job demands and

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control (demand-control quadrants), can affect was reported earlier by Choobineh et al. (19). Each
workers’ health. Several studies have investigated how item was scored on a four-point Likert scale (ranging
this interaction between job demands and job control from “often” to “never” or “strongly agree” to
is related to MSD development in industrial workers “strongly disagree”). The dataset’s median of scores
(15-17), but only a few have looked into the prevalence for psychosocial demands and job control (decision
of MSDs among healthcare workers. This issue is latitude) served as a cut-off to divide the participants
particularly poorly covered in the nursing profession. into Karasek’s job strain quadrants (14) of high or low
Since nursing is a stressful, highly demanding job with demand and high or low control jobs and to apply
low control, the aim of this study was to investigate these quadrants to assign each participant to their own
the effects of psychosocial job strain on the prevalence demand-control group. The first group, called the
of back symptoms in nursing personnel using the “active job” group, is characterised by high demand
demand-control model. and high control (usually associated with high-prestige
jobs like physicians, engineers, and managers). The
second, “passive job” group is characterised by low
METHODS demand and low control (clerical jobs, janitors). The
third, “high strain” group is characterised by high
demand and low control (nurse’s aides, assemblers,
Participants
cutting operatives, waiters), and the fourth, “low
This cross-sectional study was conducted in 2011 strain” group by low demand and high control (self-
and included nursing professionals (head nurses, paced occupations such as repairmen and linemen)
nurses, nurses’ aides, office nurses at administrative (14). Physical demand was assessed with five four-
jobs, and nurse technicians) from a public hospital in point-scale questions from the JCQ (body in awkward
Tehran, Iran with at least one year of work experience position, lifting or lowering objects/patients, bending
at current job. The exclusion criteria were MSDs or twisting at waist, pushing/pulling heavy objects/
caused by trauma or rheumatologic disorders and patients, and standing still). For each physical item,
incomplete response to the questionnaire. Of the 695 scores one and two were considered low and scores
invited participants, 587 returned the questionnaire three and four high physical demand.
(response rate=84.5 %), of whom 42 were excluded The third set of questions drew from the Nordic
based on exclusion criteria, so that data analysis questionnaire (20) and was related to participants’ LBS
included 545 questionnaires (78.4 %). All participants and UBS experienced over the past 12 months that
gave informed consent in writing and the study was had disrupted their daily activities (at work and/or
approved by the ethics committee of the Tehran home). With a simple “yes” or “no” the participants
University of Medical Sciences. were asked to answer if they had musculoskeletal
symptoms such as pain, tingling sensation, numbness
Data collection and stiffness, and limited movement in either the lower
We used one questionnaire covering three sets of back or upper back area, as shown on a picture
questions. The first set was used to collect personal, delineating the two areas.
job, and health information (such as gender, age,
marital status, education, smoking, exercise, BMI, Statistical analysis
work hours, work schedule, and history of chronic All analyses were run with the SPSS version 11. For
conditions and injuries to the back such as slipped quantitative variables we calculated the means and
disc, tendonitis, or fractures), and information on standard deviations (SD). Chi-square and ANOVA tests
psychosocial factors and musculoskeletal symptoms. were used to determine the distribution of all potential
The participants were divided into day workers and covariates across the job strain quadrants. Psychosocial
shift workers. Shift work was considered work on demands groups, job control groups, and demand-control
hours other than normal daylight hours (7:00 a.m. to groups were compared in terms of the frequency of back
6:00 p.m.) (18). symptoms. Logistic regression analysis adjusted for
The second set corresponded to the Persian version confounding factors was used to investigate the
of Karasek’s Job Content Questionnaire (P-JCQ) and association between psychosocial demands, job control,
was used to measure psychosocial strain based on the and job strain with the prevalence of LBS and UBS.
demand-control model (14). Its reliability and validity Quantitative variables such as age, years of work, and

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BMI were divided in two categories, using the median groups. These groups did not significantly differ in
as a cut-off value. Smoking was divided in two categories: gender, BMI, smoking status, or exercise. The high
smokers and non-smokers. Exercise was divided in three strain group had significantly lower mean age and
categories: regular (at least three half-hour sessions per years of work than the other groups (p≤0.05). The
week), irregular, and no exercise. We also used regression passive job group significantly differed from the other
analysis to test associations between gender, work groups in the distribution of shift and day workers
schedule, and years of work (the variables that were (p=0.02). Regarding physical demand, the frequency
associated with back symptoms in the main regression of awkward posture, bending/twisting at waist, and
analyses) with back symptoms for each demand-control standing still, the group with the highest prevalence
group. Statistical significance was set at 0.05 (two-tailed) of either parameter significantly differed from the
for all tests. Odds ratios (OR) were reported with the group with the lowest prevalence of the same
95 % confidence interval (95 % CI). parameter (p≤0.05).
The overall prevalence of LBS was 58.5 % and of
UBS 47.9 %. Table 2 shows this prevalence by
RESULTS demand-control groups. The highest prevalence was
observed in the high strain group (p≤0.05). The
Table 1 shows the demographic and occupational prevalence in the high demand group was significantly
characteristics of the study participants by job strain higher than in the low demand group (p≤0.05),

Table 1 Demographic and occupational characteristics by job strain groups

Job Strain Groups

Low High Active Passive
All
Variables strain strain job job p
participants
(N=125) (N=102) (N=117) (N=201)
Age1 / year Mean (SD) 32.1 (7) 33.0 (8.2) 30.4 (5.4) 32.8 (6.7) 31.9 (6.9) 0.021
Work experience1 /
Mean (SD) 8.5 (6.3) 10.0 (7.6) 6.9 (5.2) 8.9 (6.4) 8.2 (5.6) 0.002
year
Work experience2 / year 0.056
≤7 N (%) 304 (55.8) 61 (48.9) 68 (66.7) 63 (53.9) 112 (55.7)
>7 N (%) 241 (44.2) 64 (51.1) 34 (33.3) 54 (46.1) 89 (44.3)
2
Gender 0.623
Female N (%) 433 (79.4) 97 (77.6) 83 (81.4) 97 (82.9) 156 (77.6)
Male N (%) 112 (20.6) 28 (22.4) 19 (18.6) 20 (17.1) 45 (22.4)
Exercise2 0.249
Yes regular N (%) 48 (8.8) 16 (12.8) 4 (3.9) 9 (7.7) 19 (9.5)
Yes irregular N (%) 254 (46.6) 57 (45.6) 45 (44.1) 60 (51.3) 92 (45.8)
No N (%) 243 (44.6) 52 (41.6) 53 (52.0) 48 (41.0) 90 (44.7)
Work schedule2 0.02
Day Work N (%) 196 (36.0) 41 (32.8) 30 (29.4) 36 (30.8) 89 (44.3)
Shift Work N (%) 349 (64.0) 84 (67.2) 72 (70.6) 81 (69.2) 112 (55.7)
Physical demands2
(High)
Awkward posture % 49.5 40.6 54.4 59.2 38.5 0.002
Lifting/lowering objects/
% 35 33 36.8 38.5 29.7 0.512
patients
Bending/twisting % 52.3 54.7 55.9 58.6 35.2 0.003
Pulling/pushing objects/
% 37.8 34.9 45.6 40.2 30.8 0.215
patients
Standing still % 46.1 49.1 54.4 48.5 31.9 0.018
1 2
ANOVA and Chi-square tests were used to test the differences between study groups

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Table 2 Prevalence of back symptoms by demand, control, and job strain groups
Lower back Upper back
Variable Status % p % p
Job control Low 54.8 0.054 46.5 0.491
High 63.2 49.6
Psychosocial demands Low 53.1 0.002 43.3 0.009
High 66.7 54.8
Job strain Low Strain 61.6 0.001 46.4 0.043
High Strain 68.6 56.9
Active 65.0 53.0
Passive 47.8 41.3

whereas in the job control groups the difference was p≤0.05) and UBS was significantly more common in
not significant. the high strain group than in the passive group
Table 3 shows the results of multivariate analysis (OR=1.82 and p=0.019).
of associations between demand, control, and job Table 4 shows that female gender, work experience
strain and the prevalence of back symptoms. After of more than seven years, and shift work correlated
adjustment for confounding factors, job control significantly with back symptoms (p≤0.05). LBS and
showed no statistically significant associations with
UBS were 2.63 and 2.06 times more common in
back symptoms, but psychosocial demands did
women than in men (p≤0.05), 3.14 and 2.28 times
(p≤0.05). High psychosocial demands were associated
with an increased risk of LBS and UBS. LBS was more common in participants working more than
significantly more common in the low strain, high seven years than those working seven years or less
strain, and active job groups than in the passive group (p<0.001), and LBS was 1.66 times more common in
(OR=1.64, OR=2.49 and OR=1.90 respectively; shift than day workers (p=0.012).

Table 3 Association between back symptoms and psychosocial demands, job control, and job strain using multivariate
analysis
Lower back Upper back
Adjusted Adjusted
Variable Status 95 % CI p 95 % CI p
OR OR
Passive 1.00 – – 1.00 – –
Low strain 1.64 1.01 to 2.66 0.045 1.14 0.72 to 1.81 0.584
Job strain groups
High strain 2.49 1.46 to 4.26 0.001 1.82 1.10 to 3.01 0.019
Active 1.90 1.15 to 3.12 0.012 1.52 0.95 to 2.44 0.083
Low 1.00 – – 1.00 – –
Job control
High 1.21 0.83 to 1.76 0.314 1.01 0.70 to 1.43 0.996
Low 1.00 – – 1.00 – –
Psychosocial demands
High 1.73 1.18 to 2.53 0.005 1.57 1.09 to 2.25 0.014
Physical demands
Low 1.00 – – 1.00 – –
Awkward posture
High 2.59 1.61 to 4.19 0.000 2.45 1.57 to 3.83 0.000
Lifting/lowering objects/ Low 1.00 – – 1.00 – –
patients High 1.15 0.63 to 2.11 0.646 0.83 0.47 to 1.47 0.528
Low 1.00 – – 1.00 – –
Bending/twisting
High 1.29 0.79 to 2.13 0.309 1.66 1.03 to 2.66 0.036
Pulling/pushing objects/ Low 1.00 – – 1.00 – –
patients High 0.98 0.55 to 1.74 0.948 0.99 0.58 to 1.69 0.984
Standing in static Low 1.00 – – 1.00 – –
position High 1.71 1.07 to 2.74 0.024 1.56 1.01 to 2.41 0.046
Gender, age, BMI, smoking, exercise, work schedule, and years of work were used as confounders in the logistic regression analysis

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DISCUSSION model as another viewpoint of psychosocial factors

in a larger population of hospital nurses.
The main findings of our study were that nursing The demand-control model has been used to
personnel working in low strain, high strain, and active investigate the relationship between psychosocial
jobs had higher prevalence of LBS than those with factors and the incidence of shoulder symptoms in
passive jobs and that the prevalence of UBS was other professions. Smith et al. (15) found that having
significantly greater in the high strain jobs than passive either a passive or high-strain job was associated with
jobs. Subjects working in high psychosocial demand higher incidence of shoulder symptoms. The same was
jobs experienced more back symptoms than subjects true for low control. Their findings are in contrast with
in low demand jobs, but we found no association ours, as our nurses in passive jobs had the lowest
between job control and back symptoms. These prevalence of back symptoms and only high demands
findings suggest that decreasing psychosocial demands were associated with back symptoms. Rugulies et al.
may lower the prevalence of back symptoms among (11) found no correlation between job strain (a
nurses. However, this hypothesis should be confirmed combination of high psychological demands and low
by further prospective studies. job control) or iso-strain (job strain plus low social
In a study by Mehrdad et al. (21), high psychosocial support at work) and low back injuries in public
stress level (assessed by General Nordic Questionnaire transport operators. Some other studies support our
for Psychological and Social factors at work) findings. Ghaffari et al. (12) investigated the effect of
significantly correlated with UBS, but not with LBS. psychosocial factors on low back pain in a cohort of
The most similar study to ours in terms of methods 4,500 Iranian industrial workers. They found that
and results was the one by Choobineh et al. (22), who employees with high demands, low control, job strain,
found a significant correlation between high low job satisfaction, and low job appreciation had
psychological demands (established with Karasek’s increased incidence of low back pain (12). Hannan et
JCQ) and the prevalence of MSDs in operation room al. (16) studied the effects of job strain and risk of
nurses. However, unlike all of the above mentioned musculoskeletal symptoms among occupational
studies, our study focused on the demand-control computer users. They concluded that workers who

Table 4 Association between gender, work experience, and shift work with back symptoms in the total population and each
demand-control group separately
Lower back Upper back
Adjusted Adjusted
Variable Study Group 95 % CI p 95 % CI p
OR OR
All participants 2.63 1.65 to 4.17 0.000 2.06 1.30 to 3.26 0.002
Low strain group 2.02 0.80 to 5.12 0.140 1.48 0.57 to 3.74 0.407
Gender
High strain group 2.90 0.94 to 8.97 0.064 0.95 0.31 to 2.88 0.926
(Female)
Active group 6.89 1.93 to 24.57 0.003 6.35 1.84 to 21.99 0.004
Passive group 1.99 0.93 to 4.24 0.075 2.38 1.08 to 5.21 0.031
All participants 3.14 1.97 to 5.00 0.000 2.28 1.46 to 3.56 0.000
Work Low strain group 1.14 0.41 to 3.19 0.809 1.39 0.51 to 3.80 0.519
Experience High strain group 5.27 1.37 to 20.27 0.016 4.64 1.33 to 16.15 0.016
(>7 years) Active group 8.22 2.05 to 32.98 0.003 3.01 0.94 to 9.67 0.064
Passive group 3.38 1.71 to 6.65 0.000 2.11 1.09 to 4.09 0.027
All participants 1.66 1.12 to 2.46 0.012 1.40 0.96 to 2.04 0.080
Work Low strain group 2.25 0.96 to 5.27 0.062 1.98 0.86 to 4.57 0.110
Schedule High strain group 1.27 0.45 to 3.58 0.649 2.37 0.89 to 6.31 0.084
(Shift Work) Active group 2.45 0.86 to 6.96 0.092 0.89 0.35 to 2.27 0.818
Passive group 1.46 0.79 to 2.67 0.224 1.14 0.63 to 2.08 0.667
Each variable compared with reference. The reference group for gender was male, for work experience ≤7 years, and for work
schedule day work
Age, BMI, smoking, and exercise were used as confounders in the logistic regression analysis

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reported high job strain were more likely to develop psychosocial demands in particular. Future research
neck-shoulder symptoms (16). In a six years should also focus more on nursing subgroups, so that
longitudinal study with 2,556 middle-aged men and the preventive programme could address the specific
women, Clays et al. (10) found that baseline low issues of head nurses, nurses, nurse’s aides, and so on.
decision latitude (low control) correlated with the
incidence of low back pain in men.
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Sažetak

UTJECAJ PSIHOSOCIJALNIH ZAHTJEVA NA NASTANAK BOLOVA U LEĐIMA U MEDICINSKIH

SESTARA I TEHNIČARA OPĆE BOLNICE U TEHERANU

Poslovi na zdravstvenoj njezi stresni su i vrlo zahtjevni. Svrha je ovog presječnog ispitivanja bila utvrditi
povezanost između psihosocijalnih zahtjeva posla i prevalencije bolova u leđima u medicinskih sestara i
tehničara prema Karasekovu modelu zahtjeva i kontrole. Analizirani su odgovori 545 njegovatelja na
upitnik o demografskim podatcima, sadržaju posla te simptomima u donjem i gornjem dijelu leđa (SDL
odnosno SGL). Na temelju odgovora sudionici su raspoređeni u sljedeće skupine: niski zahtjevi, visoki
zahtjevi, aktivni posao i pasivni posao. Skupine su uspoređene s obzirom na prevalenciju simptoma u
donjem (58,5 %) odnosno gornjem dijelu leđa (47,9 %) u proteklih godinu dana. Nije utvrđena povezanost
između kontrole i bolova u leđima, ali su sudionici s visokim psihosocijalnim zahtjevima iskazali viši rizik
od nastanka simptoma u donjem dijelu leđa (OR=1,57; p=0,014) odnosno gornjem dijelu leđa (OR=1,73;
p=0,005) od sudionika s niskim zahtjevima posla. Simptomi u donjem dijelu leđa bili su učestaliji u
skupinama s niskim zahtjevima, visokim zahtjevima i aktivnim poslom negoli u skupini s pasivnim poslom
(OR=1,64, OR=2,49 odnosno OR=1,90; p≤0,05). Osim toga, skupina s visokim zahtjevima imala je veću
prevalenciju simptoma u gornjem dijelu leđa od skupine s pasivnim poslom (OR=1,82; p=0,019). Rezultati
ovog ispitivanja upućuju na to da poslovi s visokim psihosocijalnim zahtjevima mogu biti povezani s
većim rizikom od bolova u leđima u medicinskih sestara i tehničara te pružaju korisne podatke za
osmišljavanje preventivnih mjera kojima bi se smanjila prevalencija poremećaja mišićno-koštanog sustava
u ovoj profesiji.

KLJUČNE RIJEČI: bol, donji dio leđa, gornji dio leđa, mišićno-koštani sustav, njegovatelji, stres

CORRESPONDING AUTHOR:

Mohamad Namvar
Tehran University of Medical Sciences,
Department of Occupational Medicine
Hazrat Rasoul Hospital, PO Box 14155-5983, Tehran, Iran
E-mail: mohamad.namvar@gmail.com

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Download Date | 4/3/17 11:57 AM