Sage Journals: Discover world-class research

Abstract

Today’s employers are hiring a more age-diverse workforce. As Americans work longer, age-related changes often create activity limitations. Musculoskeletal disorders affect many older workers heightening their risk of workplace injury. Compounded by multiple comorbidities, older workers will need occupational health nurses with expert knowledge to maintain safe and productive workplaces. Older workers do not experience as many injuries as younger workers, but when they are injured, recovery is longer. The author developed and conducted a survey of New Jersey occupational health nurses. The results showed that overexertion injuries are the most frequently treated injuries in employee health offices. For occupational health nurses to keep employees safe, best practices must be delineated; this musculoskeletal safety guideline provides recommendations for evidence-based care of older workers.

Keywords

international aging workforce safety age-related changes

Research indicates that over 20% of the U.S. population will be at least 55 years old by the year 2050 increasing the prevalence of chronic illness, musculoskeletal disorders, and occupational as well as non-occupational musculoskeletal injuries in older adult workers (Canning & Bloom, 2012). In addition, many older adults are choosing not to retire as early as previous generations. These trends suggest occupational health nurses and advanced practice nurses working in occupational health will be providing nursing care for a rapidly increasing elderly workforce employed in manufacturing and nonmanufacturing settings. These changes, leading to a new “multigenerational” workforce with multiple comorbidities, will require nurses with expert knowledge to evaluate and manage older employees with musculoskeletal injuries. Safety for the older worker must be a priority.

Besides changes in vision and hearing and decreased strength and flexibility, older adults experience musculoskeletal changes that can result in arthritis (Blagojevic, Jinks, Jeffrey & Jordan, 2010; Keller & Burns, 2010). To compound this physiological effect, the incidence of arthritis increases to one of every two individuals aged 65 years and older (Caban-Martinez et al., 2011). Research has documented how aging affects human body systems but evidence-based safety guidelines for older workers could provide the foundation for occupational health nurses to develop strategies and gain insight into the future nursing care needed by this population.

Needs Assessment

The increase in aging workers will bring challenges for nurses providing care to older adults. A sound educational foundation of how aging affects individuals’ risk of injury is extremely important for nurses in the workplace. Having this knowledge should lower workers’ risk of musculoskeletal injury. Occupational health nurses care for employees who have been injured on and off the job. For this reason, they are essential members of the health care team.

The need for a musculoskeletal safety guideline as a resource for occupational health nurses was identified by the author after participating in informal discussions with New Jersey occupational health nurses. The author conducted a series of 12 face-to-face or teleconference interviews with musculoskeletal experts from physical therapy, occupational therapy, ergonomics, workplace design, safety, and advanced practice nursing to understand content that should be included in the development of a safety guideline.

To evaluate the prevalence of musculoskeletal disorders, particularly overexertion injuries, a survey was sent to New Jersey occupational health nurses to determine the three most common types of injuries the nurses identified in their offices. The survey included questions to determine whether any policies or musculoskeletal safety guidelines were used in New Jersey organizations and the types of charting procedures occupational health nurses were using. To search for strong evidence to support the guideline, an extensive review of the literature using key words (e.g., international aging workforce, safety, and age-related changes) was completed. To identify if a gap existed in this area of research, three national occupational health nurse experts used the Agree 2 evaluation tool to compare the strengths and weaknesses of three national guidelines. This instrument is used to evaluate the quality of an existing guideline and newly developed guidelines being considered for clinical practice (Brouwers et al., 2010).

Method

The search engines for the literature review were Medline, CINAHL, Business Source Primer and Google Scholar. Thirty-two articles were reviewed. Five studies were rejected because they did not meet the inclusion criteria (i.e., publications in English and articles that reviewed age-related changes and ergonomic impact) and exclusion criteria (i.e., data published before January 2005, publications focusing on chronic disease, unpublished works, individuals aged 55 or younger, and emphasis on the psychosocial impact of occupational injury rather than musculoskeletal disorders or injuries).

Next, a doctoral committee was assembled to guide the project. The committee members were chosen for their expert knowledge needed for the development and implementation of the project. Because “older adults” were the target population, an expert in adult and gerontology nursing was selected to review the disease content and chair the committee. The guideline was meant to be used by occupational health nurses in all types of organizational settings. So, a nurse expert in leadership was chosen to provide organizational management of the project. The final committee member was a statistical expert to assist in data analysis.

The external reviewers were three individuals considered experts in the field of occupational health nursing. One university professor in the group is well recognized as a musculoskeletal injury researcher. The second reviewer is a university professor and expert reviewer of scholarly publications for peer-reviewed journals. The third reviewer is a university clinical professor in the field of community health.

The Agree 2 evaluation was applied to national guidelines by two of the three occupational health nurse experts. The musculoskeletal injury researcher reviewed the initial draft of the musculoskeletal safety guideline later developed by the author. This instrument was used to appraise the American College of Occupational and Environmental Medical Specialty Society Low Back Disorders: Evaluation and management of common health problems and functional recovery in workers (American College of Occupational and Environmental Medicine [ACOEM], 2009), Hartford Institute for Geriatric Nursing Academic Institute for Age-Related Changes in Health (Smith et al., 2008), and the American Occupational Therapy Association’s Occupational Therapy Practice Guidelines for Individuals With Work-Related Injuries and Illnesses (Kaskutas & Snodgrass, 2009).

After the Agree 2 evaluations were completed, a comparison table was developed by the author to identify key elements that should definitely be included in the musculoskeletal safety guideline (Table 1). The rigorous evaluations demonstrated that no quality nursing guidelines were available for nurses to identify age-related risk factors. The highest Agree 2 rating was given to a medical guideline. These evaluations further supported the need for a standardized nursing guideline. The Center of Evidence-Based Medicine (CEBM) levels of evidence were used for rating all five main articles included in the evidence table (Phillips et al., 2009). The guideline was further supported by the use of additional relevant articles.

Table 1.

Agree 2 Evaluation of National Guidelines

Elements	ACOEM	HIGN	AOTA
Scope and purpose health question	Present	Present	No patient outcomes
Clarity of presentation	Present	Not consistent	Present
Applicability	No plan included	Absent	Present
Editorial independence	Present	Missing	Present
Rating score	5/7	3/7	4/7
Stakeholder involvement	Absent	Present	Present
Target users	Present	Present	Present
Population	Present	Present	Present
Rigor	Present	Not complete	Present

Note. ACOEM = American College of Occupational and Environmental Medicine; HIGN = Hartford Institute for Geriatric Nursing; AOTA = American Occupational Therapy Association.

Table 2.

Synthesis of Evidence and Levels of Evidence

Author/year title	Study topic/problem	Intervention	Outcome	Results	Comments	Level of evidence
1. Blagojevic, Jinks, Jeffery, and Jordan (2010) Risk factors for onset of osteoarthritis of the knee in older adults: a systematic review and meta-analysis	Lack of systematic reviews for osteoarthritis of the knee.Higher prevalence of osteoarthritis in the knee with adults over age 50	All types of review publications from 1960 to January of 2008	Prevention factors	2,233 studies were found, 85 studies were used.Predisposition—history of knee trauma, Heberden’s nodes, obesity, job-related (stooping), advancing age and female gender	Further longitudinal studies needed,Gender biasMeta-analysis limitation noted identification of few contributing factors to sustaining an injury.Cohort and case–control studies revealed similar conclusions, case–control studies had larger effect sizes	Level 1ASR and MA.Included cohort as well as case–control studies
2. Crawford, MacCalman, and Jackson (2011).The health and well-being of remote and mobile workers	Probable medical and psychosocial implications for workers	Systematic reviews have shown the musculoskeletal medical and psychological effects that affect well-being	Musculoskeletal complaints can be reduced with ergonomic screening.Risk of social isolation and mental health issues heighten without enough social interaction	280 studies reviewed, 11 articles calculated the correlation between musculoskeletal symptoms, work impact and lifestyle.Strong evidence that most frequent injury sites are neck, shoulder, and lower back(CI [1.72, 4.43]) correlating neck complaints and female gender.Increased musculoskeletal problems found when sitting at least 10 hours/week, driving in excess of 20 hours/week and prolonged distance driving	Further research needed to determine if access to OH care is a problem.Transporting heavy objects to and from vehicles predisposes the worker to back issues.Age-related physiological alterations need consideration in regard to lower injury rates	Level 1ASR and RCT;Quasi-experimental and observational
3. da Costa and Vieira (2010) Risk factors for work-related musculoskeletal disorders: A systematic review of recent longitudinal studies	Data can help the OH team design interventions that lower injury risk	Systematic longitudinal review to determine work-associated factors vs. NIOSH findings	Review only covered cohort and case–control studies; first published evidence on body locations	63 studies, reasonable evidence concluding biomechanical risk factors (i.e., repetitive motion, heavy lifting and poor posture) show causal association with WMSD	Weak evidence exists for pushing the musculoskeletal system beyond its capacity. Needs further investigation	Level 1ASR.Cohort and case control
4. Linton (2001) Occupational psychological factors increase the risk for back pain: A systematic review	Prompt recognition of work-associated factors will improve back pain treatment and disability.Identification of age-related physiological changes is vital to preventing future disability	Systematic review of psychological workplace elements in relation to back pain.Outcome variables included injury, lost time, and return to work	Strong evidence showed that tiresome work, work relationships, job fulfillment, job stress, and job requests influence future back pain in older workers	21 studies encompassed prospective design, evaluation, monitoring, comparative, randomized clinical trials (RCT), and clinical trials.Most clinical trials lacked data on psychological predictor variables so the author did not use them	Awareness of work-related psychological factors to prevent injury and hasten rehabilitation.Data from only 2 studies and use of questionnaire were limitations of this study.Attributable fraction of female back pain reduction (0% effect on recovery of lost time to more than 1 week to 66% for job satisfaction).Data indicate it is desirable to lower or eradicate these risk factors	Level 1BSR.Prospective studies used

Note. CI = confidence interval; SR = systematic review; MA = meta-analysis; RCT = randomized control; OH = occupational health; NIOSH = National Institute for Occupational Safety; WMSD = work-related musculoskeletal disorders; Level 1A = systematic reviews (with homogeneity) of randomized controlled trials; Level 1B = individual randomized controlled trials (with narrow confidence interval).

Table 3.

Additional Research Supporting Development of Evidence-Based Safety Guideline/Educational Program

Author/year title	Study topic/problem	Intervention	Outcome	Results	Comments
Agnew et al. (2007) Use of employer administrative databases to identify systematic causes of injury in aluminum manufacturing	Employee files are underutilized in epidemiological studies examining injuries	Employee files, occupational health surveillance data and industrial hygiene data	Physical job demand shown to be the strongest predictor in determining employee injury risk level	2,495 workers studied from the period 2002-2004, found 32% suffered sprains, 24% contusions, and 14% lacerationsLogical regression model to evaluate data	Employer administrative records found to be a useful source of data because utilizing these records allows risk factor analysis and identification of potential confounders
Alipour et al. (2008). Occupational neck and shoulder pain among automobile manufacturing workers in Iran	Upper extremity musculoskeletal injuryconstitutes a problem experienced throughout the world	MSD Questionnaire	Ergonomic deficiencies linked to problems with the musculoskeletal system resulting in illness or injury	14,384 workers participated in completing the MSD Questionnaire. Several risk factors were identified from the questionnaire data such as repetitive motion, working in awkward positions, prolonged sitting, and lack of consistent exercise	Multiple logistic regression model. Physiological manifestations and psychosocial factors linked to neck and shoulder complaints
Cassou, Derriennic, Monfort, Norton, and Thouranchet (2002). Chronic neck and shoulder pain, age, and working conditions: longitudinal results from a large random sample in France	Determining how aging and work relate to chronic neck and shoulder pain	Participants completed a questionnaire addressing pain and psychosocial job issues through random selection	Multifactorial nature exists with job strain due to imbalance of physical workload and physical workload capacity was found to be a determinant in future development of MSDs with advancing age	Advancing age increases prevalence and incidence of WMSDMore prevalent in females	Findings indicate that proper ergonomic adaptation and early management of chronic neck and shoulder pain for aging workers is vital for injury prevention.Prospective longitudinal study
Harvey and Thurnwald (2009). Ageing well, ageing productively: The essential contribution of Australia’s ageing population to the social and economic prosperity of the nation	In dealing with aging workers, management should consider alternative views and solutions to address social and economic outcomes	Descriptive review on societal influences on aging	A disparity was identified between rich and poor individuals over age 65	Current generation is more knowledgeable than previous generations about aging gracefully	Improved illness treatment have had a positive impact on living longer
Leino and Hanninen (1995). Psychological factors at work in relation to back and shoulder disorders	Identification of factors that lead to neck, shoulder, and low back pain that potentiates risk of injury	Study duration of 10 years using a questionnaire and performance of a clinical exam	Results found statistical significance between the level of stress and musculoskeletal complaints	An investigation of how morbidity is affected by gender and occupational class.Data were analyzed by two-way analysis of variance.Research finding: prolonged mental strain is associated with WMSDs	On-the-job psychosocial factors play a major role in determining positive effects on WMSDs considering age and physical workload

Note. MSD = musculoskeletal disorder.

After the previous steps were completed, a comprehensive evidence-based safety guideline to lower the risk of musculoskeletal injuries was developed from an in-depth literature review, expert reviewers, and evaluation of three national guidelines using the results of the Agree 2 evaluations. The intended users of this guideline are occupational health nurses and advanced practice nurses. The recommendations below are intended to increase occupational health nurses’ knowledge of assessment, education, and evaluation of age-related risk factors for musculoskeletal injuries.

The following is a synopsis of the recommendations from the comprehensive guideline:

Age-related musculoskeletal changes increase injury risk for older adults (Bohle, Pitts, & Quinlan, 2010; Centers for Disease Control and Prevention, 2009; da Costa & Vierira, 2010; Foster, Hartvigsen, & Croft, 2012; Hush, Cameron, & Mackey, 2013; Perry, 2010). Prompt detection of musculoskeletal symptoms is paramount to improving injury rates and recurrent injuries.

While gathering a musculoskeletal history, concentrate on symptomology that can precipitate overexertion injuries or result in falls.

Conduct a fall risk evaluation of older workers by using the Hendrich 11 Fall Risk Model (retrieved from http://consultgerirn.org/uploads/File/try_this_8.pdf)

When documenting health histories, record the onset of chronic conditions to calculate workers’ injury risks. Health issues that lower physical activity increase the risk of musculoskeletal injury (Linton, 2001).

“When taking a psycho-social history, factors such as self-imagined age, work\home balance, social support, work breaks, job satisfaction, supervisor and employee working relationship, socialization, relaxation methods and sleep patterns can increase risk of injury” (Hauke, Flintrop, Brun, & Rugulies, 2011; Linton, 2001, pp. 56-57).

Assess for adverse medication reactions that occur with advancing age that can lead to increased risk of work-related injury.

When documenting occupational histories, the time workers have been functioning in an ergonomically demanding environment is important to identifying injury risk (Agnew et al., 2007; Cassou, Derriennic, Monfort, Norton, & Touranchet, 2002).

Use an age-sensitive manner when examining older employees (Leggert, 2007).

When examining older workers for musculoskeletal issues, focus on the areas of the body where injury tends to occur: “eye, low back, shoulder, neck, hand, wrist, ankle and foot” (Crawford, MacCalman, & Jackson, 2011; da Costa & Vieira, 2010, pp. 32-33).

Assess the areas where workers perform job functions, and observe workers engaged in daily activities. This process will determine how much ergonomic factors influence workers’ risk and complaints.

Refer workers as soon as possible to physical therapy and occupational therapy to lower absenteeism rates (Foster et al., 2012).

Increase workers’ knowledge of low back risk factors: bending, twisting, pulling, pushing, reaching, climbing, and prolonged sitting (da Costa & Vieira, 2010; Leino & Hanninen, 1995).

Encourage rotation of sitting and standing while completing job tasks (Alipour, Ghaffari, Shariati, Jensen & Vingard, 2008).

The glenohumeral joint should be examined. This is the most unstable joint when engaged in hand-operated workplace activities (Seidel et al., 2011).

Older workers can suffer loss of consciousness from postural hypotensive changes (Harvey & Thurwald, 2009; Perry, 2010). Instruct older workers to move slowly when standing and sitting.

Encourage older workers to walk. Instruct employees that not enough exercise can interfere with coordination, balance, flexibility, and strength. These areas are already compromised with advancing age (Kravitz & ACOSM, 2011; ACOEM Clinical Practice and Guideline Center, 2012).

Cardiovascular disease negatively affects older workers with slower healing after suffering work-related musculoskeletal injuries. Therefore, instruct older workers not to sit for extended periods of time at their desks (American College of Sports Medicine, 2011; Goff et al., 2014).

Instruct workers that “lifting 35 pounds or more and lifting more than the horizontal distance of 20 inches from the person’s ankle, increases the risk of injury” (Chaffin & Park, 1973, p. 516).

In positions requiring repetitive motion, encourage sufficient time for muscle and tendon recovery by participating in adequate rest breaks.

Conclusion

When developing an evidence-based guideline, the author must be immersed in the process using a structured organized approach for the assessment, education, and prevention of the problem. The approach used in this article to design a musculoskeletal guideline can be used as a springboard for occupational health nurses and other nurse specialties to improve their practice. Due to the shortage of evidence-based “best practices” available for registered nurses and advanced practice nurses working in occupational health and safety, these guideline recommendations will assist nurses caring for older workers to prevent musculoskeletal injuries.

Footnotes

Conflict of Interest

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Author Biography

Nancy Delloiacono received a Doctor of Nursing Practice degree, and a Post-Masters Certificate, Primary Care of the Adult and Aged Nurse Practitioner Post Master’s Program from Rutgers, The State University of New Jersey School of Nursing. She is employed at Rutgers School of Nursing as the nursing resource center coordinator and also employed as an APN-BC in home care at Universal Health Care Navigators. She has 7 years of experience as an occupational health nurse.

References

Agnew

Slade

Cantley, L., Taiwo

Vegso

Sircar

Cullen

M.R.

(2007). Use of employer administrative databases to identify systematic causes of injury in aluminum manufacturing. American Journal of Industrial Medicine, 50, 676-686. doi:10.1002/ajim.20593

Aipour

Ghaffare

Shariati

Jensen

Vingard

(2008). Occupational neck and shoulder pain among automobile manufacturing workers in Iran. American Journal of Industrial Medicine, 51, 372-379. doi:10.1002/ajim.20562

American College of Occupational and Environmental Medicine Clinical Practice and Guideline Center. (2012). Guidelines for common health problems and functional recovery in workers, healthy workforce now. American College of Occupational and Environmental Medicine. Retrieved from http://www.acoem.org/PracticeGuidelines.aspx

Blagojevic

Jinks

Jeffrey

Jordan

K. P.

(2010). Risk factors for onset of osteoarthritis of the knee in older adults: A systematic review and meta-analysis. Osteoarthritis and Cartilage, 18, 24-33. doi:10.1016/j.joca.2009.08010

Bohle

Pitts

Quinlan

(2010). Time to call it quits? The safety and health of older workers. International Journal of Health Services, 40, 23-41. doi:10.21901/HS.40.1.b

Brouwers

M. C.

Kho

M. E.

Browman

G. P.

Burgers

J. S.

Cluzeau

Feder

. . .Zitzelsberger

(2010). AGREE II: Advancing guideline development, reporting and evaluation in healthcare. Journal of Epidemiology, 63, 1308-1311. doi:10.1503/cmaj

Caban-Martinez

A. J.

Lee

D. J.

Fleming

L. E.

Tancredi

D. J.

Arheart

K. L.

LeBlanc

. . .Muennig

P. A.

(2011). Arthritis, occupational class, and the US aging workforce. American Journal of Public Health, 101, 1729-1734. doi:10.2105/AJPH.211.300173

Canning

Bloom

(2012). How companies must adapt for an aging workforce. Harvard Business Review. Retrieved from https://hbr.org/2012/12/how-companies-must-adapt-for-a/

Cassou

Derriennic

Monfort

Norton

Thouranchet

(2002). Chronic neck and shoulder pain, age, and working conditions: Longitudinal results from a large random sample in France. Occupational Environmental Medicine, 59, 537-544. doi:10.1136/oem.59.8.537

10.

Centers for Disease Control and Prevention. (2009). Data and statistics. Retrieved from www.cdc.gov/arthritis/data_statistics.htm

11.

Chaffin

D. B.

Park

K. S.

(1973). A longitudinal study of low-back pain as associated with occupational lifting factors. American Journal Industrial Hygiene Association, 34, 513-525.

12.

Crawford

J. O.

MacCalman

Jackson

C. A.

(2011). The health and well-being of remote and mobile workers. Occupational Medicine, 61, 385-394. doi:10.1093/occmed/kqr071

13.

da Costa

Vieira

E. R.

(2010). Risk factors for work-related musculoskeletal disorders: A systematic review of recent longitudinal studies. American Journal of Industrial Medicine, 53, 285-323. doi:10.1002/ajim.20750

14.

Foster

N. E.

Hartvigsen

Croft

P. R.

(2012). Taking responsibility for the early assessment and treatment of patients with musculoskeletal pain: A review and critical analysis. Arthritis Research & Therapy, 14, Article 205. doi:10.1186/ar3743

15.

Goff

D. C.

Jr. Lloyd-Jones

D. M.

Bennett

Coady

D’Agostino

R. B.

Gibbons

. . .Tomaselli

G. F.

(2014). ACC/AHA guideline on the assessment of cardiovascular risk: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation, 129, S74-S75. doi:10.1161/01.cir.000043774/.48606.98/./DCI

16.

Harvey

Thurnwald

(2009). Ageing well, ageing productively: The essential contribution of Australia’s ageing population to the social and economic prosperity of the nation. Health Society Review, 18, 379-793.

17.

Hauke

Flintrop

Brun

Rugulies

(2011). The impact of work-related psychosocial stressors on the onset of musculoskeletal disorders in specific body regions: A review and meta-analysis of 54 longitudinal studies. Work & Stress, 25, 243-256. doi:org/10.1080/02678373.2011.614069

18.

Hush

J. H.

Cameron

Mackey

(2011). Therapy care: A systematic review patient satisfaction with musculoskeletal physical therapy. Journal of Physical Therapy, 91, 25-36. doi:10.2522/ptj.20100061

19.

Kaskutas

Snodgrass

(2009). Occupational therapy practice guidelines for individuals with work-related injuries and illnesses. Bethesda, MD: American Occupational Therapy Association.

20.

Keller

S. M.

Burns

C. M.

(2010). The aging nurse: Can employers accommodate age-related changes? Workplace Health & Safety, 58, 437-445.

21.

Kravitz

, & American College of Sports Medicine. (2011). Reducing sedentary behaviors: Sitting less and moving more. Available from http://www.acsm.org

22.

Leggert

(2007). The aging workforce: Helping employees navigate midlife. Business and Leadership, 55, 169-175. doi:10.1177/2105029/053-0487/0300-0053

23.

Leino

Hanninen

(1995). Psychosocial factors at work in relation to back and shoulder disorders. Scandinavian Journal of Work, Environment and Health, 21, 134-142. doi:10.5271/sjweh.20

24.

Linton

S. J.

(2001). Occupational psychological factors increase the risk for back pain: A systematic review. Journal of Occupational Rehabilitation, 11, 53-65.

25.

Perry

(2010, April). The aging workforce: Using ergonomics to improve workplace design. Professional Design, pp. 22-28.

26.

Phillips

Ball

Sackett

Badenoch

Straus

Haynes

Dawes

(1998, November). CEBM levels of evidence (Updated by Howick

). The Center for Evidence-based Medicine. www.cebm.net/oxford-centre-evidence-based-medicine-levels-evidence-march-2009/

27.

Seidel

H. M.

Ball

J. W.

Dains

J. E.

Flynn

J. A.

Solomon

B. S.

Stewart

R. W.

(2011). Mosby’s guide to physical examination (7th ed.). St. Louis, MO: Mosby Elsevier.

28.

Smith

C. M.

Cotter

Capezuti

Zwicker

Mezey

Fulmer

(Eds.). (2008). Age-related changes in health. In Evidence-based geriatric nursing protocols for best practice (3rd ed., pp. 431-458). New York, NY: Springer.