Prevention strategies for MSDs in the healthcare sector

Introduction

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.

Size of the problem

Employment in the healthcare sector

The healthcare 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^[1]

The healthcare sector is large, employing around 11% of workers in the European Union^[2]. Employment in the healthcare sector increased by 20% between 2008 and 2023 compared to only 5% increase in total employment^[2].. These data differ between countries but in all countries the trend towards greater numbers of people being employed in the health and social care sector continues^[3].The workforce in the health and social care sector is dominated by women with no less than 75% of workers being female. Nurses are the largest category of health and social care workers in most countries, accounting for around 20-25% of all workers^[3]

With a growing elderly population in the EU and difficulties in recruiting enough health and social care workers, the sector is likely to face future staff shortages. As life expectancy increases, the workforce is also ageing, making physically demanding tasks such as patient handling more difficult due to natural declines in strength and fitness. This presents a triple challenge: increased care demands, recruitment difficulties and an ageing workforce^[4].

Data on work-related health problems and MSDs in health and social care 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 health and social care sector consistently ranks among the top activity sector with the most work-related MSDs. Data from the European Working Conditions Survey (EWCS) show a high percentage of workers in the health and social care sector reporting MSDs. In the health and social care 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 health and social care 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 health and social care sector scores above average^[5].

Table 1: Percentage of workers reporting MSDs in the past 12 months, by sector, EU-28, 2015

Source: Panteia based on the European Working Conditions Survey (EWCS)^[5]

Comprehensive review studies (e.g. ^{[6] [7] [8] [9]}) have shown that MSDs are a widespread problem among all occupational groups in health and social care as well as in the various workplaces such as hospitals, elderly care facilities, and in home and social care. 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^[10].
Work-related musculoskeletal disorders also impose significant costs on employers, society and individuals through absenteeism (lost workdays) and amount to additional costs through disruption of care, such as bed closures, cancelled procedures, reduced service and quality of care^[11].

Risk factors

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.

Figure 1: Risk factors for MSDs

Risk factors linked to the physical workload are very common in the healthcare workforce and include: 

• lifting, carrying, or moving patients, especially when patients are immobile or uncooperative.
• awkward postures: bending, stooping, twisting, or reaching during patient care or when using medical equipment, e.g. reaching for overhead equipment or supplies; awkward postures during wound care, injections, or examinations; bending or stooping to assist patients with mobility; bending over the screen while using tablets or other devices to enter patient observations and maintain electronic records; prolonged static standing, etc.
• repetitive movements: e.g. assisting with feeding, bathing, or dressing patients, inputting data, filing, clinical laboratory work, etc.
• heavy or forceful exertion: e.g. transferring patients, transporting heavy equipment such as oxygen tanks, handling laundry or waste, pushing or pulling heavy trolleys.

ESENER data show that several of these physical workload risk factors are more common in the health and social care sector compared to other sectors (figure 2)^[4].

Home care workers are confronted with specific risk factors, since patients' homes are a less controlled work environment than hospitals or other healthcare facilities^{[16] [12]}. 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^[13].

Figure 2: Risk factors for MSDs present in the health and social care sector in 2014 and 2019 compared with all sectors in the EU-27 (Base: all establishments in the EU-27, ESENER 2014 and ESENER 2019)

Source ^[4]

Patient transfers

Several studies have pointed out the high biomechanical load on the low back of healthcare workers during patient handling activities (e.g.^[14]). Therefore, a higher number of patient transfers is an important risk factor of a higher number of work-related back pain^{[15] [10]}. 

The risk factors associated with patient transfers 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 transfers

Source: based on ^{[16] [17] [18] [19] [4]}

Risk assessment

The risk assessment process forms the basis for the prevention of MSDs in the health and social care sector. Risk assessment is a legal obligation.

Legislation

At EU level the basic principles on occupational safety and health are laid down in the Framework Directive (Directive 89/391/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^[20]. Several specific directives have been adopted based on the Framework Directive. Directive 90/269/EEC focuses on the manual handling of loads^[21]. 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^[22].

Risk assessment methods

Given that MSDs have multifactorial causes, any ergonomic risk assessment must include a systematic examination of all aspects of work. These aspects can be divided into 7 groups: Task, Patient, Environment, Equipment, Organisation, Psychosocial, and Personal factors (cfr. risk factors listed in table 2).

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^[23] provides an overview 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)

Preventive 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 for instance cannot be eliminated.

Technical interventions

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. 

Automation and robotics

Robotic applications are increasingly being introduced in healthcare to reduce the burden of repetitive and physically demanding tasks on workers^[24]. For instance, robots can assist in tasks such as lifting and moving patients, aiding in meal situations (e.g. feeding assistive robots), supporting surgeons (e.g. assistive surgical robots), and transporting instruments and equipment.

Another example of robotic applications is wearable devices like exoskeletons, which enhance the lifting capacity of healthcare workers^[24]. Back- and upper-body-assist exoskeletons have been tested for various patient-handling tasks, while passive shoulder-assist exoskeletons have been evaluated for use in operating rooms to reduce strain on healthcare staff.

Recent technological advancements have also led to the development of autonomous robots capable of transporting patients within healthcare facilities^[24]. These robots can receive transportation requests, pick up patients from their beds, and autonomously navigate through different floors, avoiding obstacles and coordinating with elevators to safely deliver patients to their designated operating rooms.

When introducing such technologies, it is essential to consider occupational safety and health (OSH) factors to avoid introducing new risks. Key considerations include^[24]:

• Human-centered design to ensure the technology is user-friendly.
• Trust in the technology, ensuring the device operates reliably and are protected against data breaches or malicious interference (cybersecurity).
• Integrated safety features (e.g. avoiding collision risks of cobots through force and speed limits on the device)
• Involvement of staff in the design process, incorporating their feedback on functionality and safety.

More information is available in the EU-OSHA report Automation of cognitive and physical tasks in the health and social care sector: implications for safety and health^[24]

Lifting aids

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^[18]:

• 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;
• sling;
• …

When selecting aids and equipment for minimising risks, several issues have to be considered:

• patient characteristics;
• organisational issues (e.g. staff numbers, 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 paid to the fact that the introduction of aids and equipment can lead to new risks. The use of lifting equipment can minimise the risk to the lower back but increase the risks to the upper limbs.

Even when lifting aids are available, they are not always used by staff. There are several barriers such as time pressure, staffing, the lack of appropriate lifting devices, the lack of teamwork/collaboration, etc. that make it difficult for staff to use lifting equipment efficiently^{[16] [27]}. Therefore, technical interventions, such as the provision of lifting aids, should always be accompanied by organisational and other accompanying measures.

Organisational interventions

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^[25]. These measures include good work planning, alternating activities, adequate work schedules, and the improved distribution of tasks. Re-organisation of work must take into account work practices, the type of patients and peaks of work at certain times of the day.

The setup of a lift-team is an organisational measure that can be used to manage manual handling risks in the healthcare sector. The lift-team concept has been developed to address those tasks that have been identified as the most hazardous for healthcare workers, specifically lifting, turning, and transferring immobile patients. Lift teams consist of at least two people, who are trained in the use of a wide variety of safe-patient-handling equipment and devices. 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^{[26] [27] [28]}. 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. 

In healthcare facilities, interventions that focus on the work environment and design aspects can reduce risks. 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 include:

• 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 focus on training programmes, information, education, the introduction of exercises, etc. These types of interventions aim to raise awareness among workers and encourage safe working practices. A key aspect is ensuring that caregivers adopt proper working postures to prevent MSDs. 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 (health surveillance) is also 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^[17]:

1. 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.
2. 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.
3. 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^[17]:

1. Always seek help/assistance if necessary
2. 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
3. Before starting any kind of handling operation, explain the procedure to the patient while also encouraging him to participate as much as possible
4. Keep a correct posture during patient handling operations
5. Get a good grip during patient handling operations
6. Wear suitable footwear and clothing

More detailed information on patient lifting techniques is available in EU-OSHA E-fact 28 Patient handling techniques to prevent MSDs in health care^[17].

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).

Comprehensive approach

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^[29]. 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^[27]. The same conclusion came out of a systematic review from the Institute of Work & Health (Canada)^[30]. Evidence suggests that practices based on multi-component patient-handling interventions can be successful. Such interventions typically include ^{[27] [28] [30] [10]}:

• worksite policy changes;
• support from management;
• employee involvement and participation;
• fostering teamwork;
• risk assessment;
• assessment of the patient characteristics;
• implementation of appropriate technical 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.

Conclusion

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.