Musculoskeletal disorders or MSDs are the leading cause of work-related health problems in the healthcare sector. The effects for staff, organisations and society include sickness absence, injuries and disability, increased costs, higher employee turnover, lower productivity and staff leaving the healthcare profession. Risk assessment is at the basis of a comprehensive approach tackling MSDs and includes technical, organisational as well as person-oriented interventions.
Employment in the healthcare sector
The health care sector encompasses a broad category of activities of hospital-based, residential and home care provided in both the public and private sectors. Health care is category Q Human health and social work activities according to the Statistical Classification of Economic Activities in the European Community (NACE rev 2) with 3 sectors:
- 86 Human health activities;
- 87 Residential care activities;
- 88 Social work activities without accommodation 
The health and social work sector is the sector with the largest rise in employment between 2009 and 2017 with over 2.6 million new jobs. The 'human health and social sector' (nace Q) accounted for 24 014 500 employees in the first quarter of 2017. Most of those, 13 601 700 employees, were employed in the 'human health' sub- sector (nace 86). The 'residential care' subsector accounted for 5 066 800 employees (nace 87), while 5 346 000 workers were employed in 'social work activities without accommodation' (nace 88) . The healthcare sector jobs accounts for 10 % of overall employment in Europe. These data differ between countries (Norway 20% and Greece 5%, data 2017) but in all countries the trend towards greater numbers of people being employed in the health and social care sector continues .
The workforce in the health care sector is dominated by women with no less than 78% of workers being female. Around 43% of workers in the sector were aged 40 or younger in 2009. However, the share of young workers has decreased markedly since 2000 while the share of workers over 50 has increased, demonstrating an ageing workforce pattern reflecting an overall trend in the EU labour market. This means that the health and social care sector not only has to accommodate the demands of an ageing population, but it has to do so with an ageing workforce .
Data on work-related health problems and MSDs in healthcare sector
Musculoskeletal disorders or MSDs denote health problems of the locomotor system apparatus, i.e. muscles, tendons, the skeleton, cartilage, ligaments, nerves or peripheral vascular system. Some MSDs are non-specific because only pain or discomfort exists without evidence of a clear specific disorder. Work-related musculoskeletal disorders (WRMSDs) include all MSDs that are induced or aggravated by work and the circumstances of its performance.
The healthcare sector consistently ranks among the top activity sector with the most work-related MSDs. Data from the Labour Force Survey (1999 and 2007) indicate that MSDs are the most reported in the agriculture sector followed by the healthcare sector. Among the reported work-related health problems in the health-care sector MSDs are ranked highest .
The data from the European Working Conditions Survey (EWCS) also show a high percentage of workers in the healthcare sector reporting MSDs. In the healthcare sector almost 1 out of 2 workers report backache (47%). It should be noted that the EWCS doesn't make a distinction between work-related and non-work-related complaints. With the figure of 47%, the healthcare sector ranks in the top 4 of the sectors where back complaints are reported most frequently (table 1). Also, for upper limb and lower limb disorders, the healthcare sector scores above average .
Table 1 - Percentage of workers reporting MSDs in the past 12 months, by sector, EU-28, 2015
|Backache||Upper limb disorders||Lower limb disorders|
|Agriculture, forestry, fishing||60%||56%||46%|
|Human health and social work activities||47%||46%||31%|
Source: Panteia based on the European Working Conditions Survey (EWCS) 
Numerous studies show high prevalence rates of MSDs of healthcare workers. Most studies focus on nurses and on low back pain . For example, a study carried out based on a survey in 10 different European countries found that on average more than 50% of the nurses are confronted with MSDs. These MSD complaints can impact the work of the nurses and hinder their regular activities. 1 out of 5 stated that neck or low back pain highly interfered with their daily activities during the last half year .
For other occupational groups such as physicians the number of studies is limited  as well as for upper limb disorders such as neck and shoulder pain . Prevalence in settings such as elderly homes and home care are also less studied but given new directions in health care, such as patients who live longer with more chronic diseases, early mobility requirements, and those who want to be at home during sickness, higher prevalence levels may shift to different populations such as home health care workers and physical therapists . Especially home health care workers are at risk considering the high physical demands .
The multifactorial causation of work-related MSDs is commonly acknowledged. Several groups of risk factors including physical and mechanical factors, organisational and psychosocial factors, and individual and personal factors may contribute to the genesis of work-related MSDs. Workers are generally exposed to several factors at the same time and interaction of these effects may aggravate adverse effects. Figure 1 illustrates the risk factors contributing to MSDs.
Risk factors linked to the physical workload are very common in the healthcare workforce such as prolonged standing, working in awkward positions, pushing and pulling and also manual handling of loads. For healthcare workers much attention has been given to the relationship between patient handling and low back pain among healthcare workers. An EU-OSHA report (2019)  could not demonstrate the relationship between self-reported low back pain prevalence and the extent to which the main paid job involves lifting or moving people. However, several studies have pointed out the high biomechanical load on the low back of healthcare workers during patient handling activities (e.g.. Therefore, a higher number of patient transfers is an important risk factor of a higher number of work-related back pain .
The risk factors associated with patient handling make these activities hazardous and increase the risk of injury. The risk factors can be found in the task itself, the fact that the "load" is a patient and therefor requires special handling techniques as well as the environment. Often patients have to be moved in cramped spaces (table 2).
Table 2: Risk factors associated with patient handling
|Force: The amount of physical effort required to perform the task (lifting, pulling and pushing)||Patients can not be lifted like loads; so safe lifting “rules" do not always apply
Patients can not be held close to the body
Patients have no handles
|Uneven work surfaces, obstacles||Lack of equipment; Inadequate equipment; difficult to use; difficult to access||No assistance available; lack of staff||High job demands, or the lack of control||Health status, age, gender|
|Repetition: frequency of the same (series of) movements||The patient may be connected to a catheter or other equipment, resulting in awkward postures||Space limitations (small rooms, lots of equipment)||Inadequate footwear and clothing||Work schedules; working at tight deadlines||Conflicting instructions and responsibilities||Lack of knowledge or training|
|Awkward positions: Assuming positions that place strain on the body (leaning over a bed, kneeling or twisting the trunk while lifting)||Patients are bulky; difficulty estimating the patient’s weight||Noise, distractions, alarm signals||Equipment not properly maintained||Working in shifts, working long hours; working nights (limited assistance available)||Time pressure||Stress, emotional pressure|
|Special lifting techniques used to minimise the load on the back may increase the load on other body parts, such as the neck, shoulders and arms||Lack of patient participation; situations which may involve handling an uncooperative or falling patient; the functional limitations of the patient (physical, mental or both) may interfere with the lift||Insufficient or inadequate lightning||Distribution of tasks||Interpersonal relationships: lack of respect and support, shortage of assistance, interpersonal conflict and harassment||Lack of responsibility, carelessness or habits|
Source: based on 
Home care workers are confronted with specific risk factors, since patients' homes are a less controlled work environment than hospitals or other healthcare facilities . Typical work characteristics of home caregivers include working in tight spaces since rooms in patients’ homes are often small or crowded. Patients' homes are usually not equipped with adjustable beds or with lifting aids. Assistance for lifting is seldom available.
In addition to the physical risk factors, it should be stressed that psychosocial factors can play an important role in the development of MSDs. Studies suggest that psychosocial factors such as high work demands and low job control, effort–reward imbalance, harassment by supervisors and low social support may be important risk factors for musculoskeletal disorders among healthcare workers .
The risk assessment process forms the basis for the prevention of MSDs in the healthcare sector. Risk assessment is a legal obligation.
At EU level the basic principles on occupational safety and health are laid down in the framework directive (directive 1989/391/EEC. This directive applies to all sectors and all employers/employees. It stipulates the general principles on risk assessment, the need to take appropriate measures and the principle of workers participation . Several specific directives have been adopted based on the framework directive. Directive 90/269/EEC focuses on the manual handling of loads . The directive prescribes that employers have to ensure that workers are protected against the risks involved in the handling of heavy loads. The directive stipulates that employers should take appropriate organisational measures, or provide appropriate means, in particular mechanical equipment, in order to avoid the need for the manual handling of loads by workers or to reduce the risks. Workers have to be informed and trained on the risks of manual handling and how these risks can be avoided. A study on the implementation of the manual handling directive in the healthcare sector revealed that most of the member states implemented the directive within two years of issue. However, only a limited number of countries have issued specific guidance for the healthcare sector to help employers in translating the general obligations from the directive to the specific context of the healthcare sector .
Risk assessment methods
Given the fact that MSDs have multifactorial causes any ergonomic risk assessment has to include a systematic examination of all aspects of work. These aspects can be divided into 4 groups: aspects related to the Task, the Individual, the Load and the Environment (TILE).
- Task: factors such as repetition of the task, body postures and physical exertion have to be considered.
- Individual: health, previous injuries, fitness level, experience, training, ability to communicate and gender.
- Load: the size, weight, shape and physical properties of the load.
- Environment: space, furniture, floor levels, temperature, etc. 
For assessing the risks of patient handling tasks several specific methods exist. ISO TR 12296 on the manual handling of people in the healthcare sector  provides an over view of recommended risk assessment methods (table 3).
Table 3: Risk assessment methods for assessing the risks of manual handling of people in the healthcare sector (ISO TR 12296)
|PTAI (Patient Transfer Assessing Instrument)||Evaluation of the risk of patient transfers
Based on observations and interviews
Risk classification into three levels
|TilThermometer (CareThermometer)||Assessment of potential exposure to physical overload|
|MAPO-Index||Analysis of determinants contributing to the risk level
Risk classification into green, yellow and red corresponding to the likelihood of acute low back pain
|Dortmund approach||Measurement of the biomechanical load on the spine, analysis of the load for the caregiver, analysis of movements both of caregiver and patient
Proposal of measures
When deciding on actions, the hierarchy of prevention has to be applied favouring technical and organisational measures above individual measures. Priority has to be giving to measures that avoid the risks of MSDs and/or manual handling. In the healthcare sector this is often very difficult. The need to move/lift/transfer patients cannot be eliminated.
Technical interventions aim to reduce the physical workload and thus also decrease the risk for MSDs. These interventions on minimising the risks related to manual handling of patients working in awkward postures , etc. For moving and handling patients the use of appropriate aids and equipment is a fundamental part of a preventive policy. These aids can minimise the risks by influencing the risk factors related to patient handling. Examples of such aids and equipment include  :
- ceiling lifts, bath lifts;
- mobile lifts, standing hoists;
- height-adjustable beds and baths:
- height-adjustable workbenches;
- sliding sheets (sheets of sturdy, low-friction material to raise, shift or reposition patients by sliding instead of lifting);
- sliding/transfer board;
- wheelchair stair lift;
When selecting aids and equipment for minimising risks, several issues have to be considered:
- the type of patients needing handling;
- organisational issues (e.g. the number of caregivers, composition of teams, peak moments);
- storage, maintenance;
- the environment where the aids have to be used (space, complementary to other aids, furniture; access);
- the level of skills required, the need for training, usability.
Special attention should be given to the fact that the introduction of aids and equipment can lead to new risks. The use of lifting equipment can minimise the risk for the low back region but increase the risks for the upper limbs.
Even when lifting aids are available, they are not always used by the caregivers. Several barriers exist such as time pressure, staffing, the lack of adequate lifting devices, the lack of teamwork/collaboration, etc. which makes it difficult for the caregivers to efficiently use lifting equipment . Therefore, technical interventions, such as the provision of lifting aids, should always be accompanied by organisational and other accompanying measures.
Working long hours (e.g. >12 hours/day, >40 hours/week) and “off hours" (weekends and “other than day shifts") are associated with MSDs due to increased exposure to high job demands. To tackle these issues preventive measures are required reducing the time of exposure to demanding work conditions and promoting healthful work–rest patterns . These measures include good work planning, alternating activities, adequate work schedules, and the improved distribution of tasks. Re-organisation of the work has to take into account work practices, the type of patients, peaks of work at specific times of the day.
The setup of a lift-team is an organisational measure that can be used for managing manual handling risks in the healthcare sector. The lift-team concept was developed to absorb the work identified as being most dangerous to nursing staff members, specifically lifting, turning, and transferring immobile patients. Lift teams are composed of at least two individuals, determined to be at low risk for musculoskeletal injury and trained in the use of the wide variety of safe-patient-handling equipment and accessories available. However, the lift team is not intended to be used for patients who are ambulating independently. When a patient is determined to be a candidate for lift team attention, the nursing staff coordinates with the lift team to ensure that the patient receives regularly scheduled rotations and spontaneously scheduled lifts and transfers until the patient is able to ambulate independently . The advantages and disadvantages of a lift team are an element of discussion. It is clear that a lift team alone is not an effective prevention measure . Moreover, the availability of a lift team does not substitute the need of a comprehensive policy based on appropriate technical aids, adequate job design, a well-designed work environment and a staff training programme. All staff should be trained in lifting techniques. Safe manual handling as well as adopting safe working postures should be an integral part of the job of all staff, not of only a dedicated team.
Work environment and design
Adjustments to the work environment covers changes to furniture, materials, ambient factors and the layout of workspaces. These changes are not always easy to implement. In the context of home care, for example, the working conditions encountered by the service providers depend largely on the fittings and fixtures already in the home and the willingness and/or financial means of the care recipients. For instance, beds are used to move patients around in many healthcare situations. This means that the design of the bed, floor surfaces, door widths, space available and work practices are important for reducing risks. It is particularly important that doors are wide enough to allow beds to be wheeled through easily. Space is important to allow access for carers to both sides of the bed. The risks from changing and making beds should be minimised by providing adequate space, appropriate bedding and work practices, and, if necessary, lifting aids. The clearances underneath beds need to be compatible with all equipment that will be used, including hoists, lifting machines and over-bed tables. In all situations where people are being handled and cared for, beds should be adjustable in height and mobile.
Ideally, managing risks on MSDs should already be integrated in the design process of new buildings, wards, rooms or in the renovation process.
Elements to consider are for instance:
- the floor surfaces;
- adequate lighting for any handling operations;
- adequate space for safe patient handling, storage facilities, …;
- width and space of routes used for patient transfer;
- storage on adequate height (not reaching below or reaching above);
- position of all fixed equipment (within easy reach);
Person-oriented interventions and training programmes
Person-oriented interventions rely on training programmes, information, education, the introduction of exercises, etc. These types of interventions are focused on raising more awareness among workers and attempting to change their working behaviour. It is important that the caregiver adopts work postures that are not harmful to the back. Information and training may include topics such as:
- working methods, workstation adjustment, use of equipment such as lifting aids;
- postural variation, task variation in procedures for each task;
- manual handling, including training in patient lifting/handling techniques;
- exercises, fitness, nutrition relaxation.
Systematic monitoring of the health of workers in healthcare is a person-oriented intervention. Health monitoring identifies workers at risk, ensures the systematic monitoring of their health and investigates work-related causal factors. This should allow early intervention actions and prevent that acute MSDs become chronic.
Training programmes for caregivers are usually focussed at patient handling techniques. Patient handling refers to the lifting, lowering, holding, pushing or pulling of patients. The methods for patient handling may be divided into three categories according to the different ways of performing them  :
- Manual transfer methods: these are carried out by one or more caregivers using their own muscular force and, wherever possible, any residual movement capacity of the patient involved.
- Transfer methods using small patient handling aids: these are patient handling techniques carried out by means of specific aids such as sliding sheets, rotatable footboards, a trapeze bar attached above the bed, etc.
- Transfer methods using large lifting aids: these handling techniques are carried out by means of electro-mechanical lifting equipment such as ceiling lifts.
The basic principles of patient lifting techniques are :
- Always seek help/assistance if necessary
- Before starting any kind of handling activity, the caregiver should position himself as close as possible to the patient, also by kneeling on the patient's bed if necessary
- Before starting any kind of handling operation, explain the procedure to the patient while also encouraging him to participate as much as possible
- Keep a correct posture during patient handling operations
- Get a good grip during patient handling operations
- Wear suitable footwear and clothing
More detailed information on patient lifting techniques is available in EU-OSHA E-fact 28 .
Manual handling training, on its own, is not an effective measure to prevent manual handling incidents, or back injuries. In order to be effective, manual handling training should be part of a comprehensive prevention programme and should be relevant to the work tasks carried out (see below).
An effective approach for preventing MSDs in the healthcare sector relies on a comprehensive approach including organisational, technical and educational measures. The need to develop a comprehensive approach is demonstrated in several studies. Martimo et al. concluded for instance that there is no evidence to support use of advice or training in working techniques with or without lifting equipment for preventing back pain . Hignett demonstrated that interventions that are only based on training on patient lifting techniques have little or no impact. However, multifactor interventions, based on a risk assessment programme, are most likely to be successful in reducing risk factors related to patient handling activities . The same conclusion came out of a systematic review from the Institute of Work & Health (Canada) . Evidence suggests that practices based on multi-component patient-handling interventions can be successful. Such interventions typically include :
- worksite policy changes;
- support from management;
- employee involvement and participation;
- fostering teamwork;
- risk assessment;
- assessment of the nature of patient and worker needs;
- the purchase and implementation of lifting handling equipment;
- storage and maintenance of equipment;
- changes in work practices;
- adaptation of the work organisation;
- work environment re-design;
- education and training of staff;
- physical training and health surveillance;
- monitoring, review and improvement of policies and strategies.
Prevention strategies to tackle MSDs in the healthcare sector combining different types of interventions oriented towards the organisation as well as to the person. Successful prevention programmes require a clear policy and strategies within the framework of a safety culture based on management support, worker participation and thorough change processes to avoid or minimise the risks associated with MSDs in the healthcare sector.
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EU-OSHA - European Agency for Safety and Health at Work, E-fact 42 - Checklist for prevention of lower limb disorders, Available at: https://osha.europa.eu/en/tools-and-publications/publications/e-facts/efact42/view