Exploring the Synergic Effects of Nursing Home Work on Work-Related Musculoskeletal Disorders Among Nursing Assistants

Abstract

Little is known about how nursing assistants (NAs) perceive the nature of their work and how their work contributes to work-related musculoskeletal disorders (WMSDs). This qualitative study addressed these gaps. Twenty-four NAs with WMSDs working in four nursing homes participated in semistructured focus group interviews. Their WMSDs were not limited to the lower back but involved several body parts. The risk factors for WMSDs included physical, psychosocial, organizational, and personal factors as well as coworkers and clients. However, it is the synergistic effects of long work hours without sufficient rest, work even with musculoskeletal pain because of staff shortages, ineffective management with insufficient prework training and inadequate equipment maintenance, and an aging workforce with strong commitment to resident care that play a crucial role in WMSDs among NAs working in nursing homes. The study found that multidimensional intervention strategies using engineering, administrative, and personal controls should be developed to reduce WMSDs among NAs working in nursing homes.

Nursing assistants (NAs) working in nursing homes are at greatest risk for work-related musculoskeletal disorders (WMSDs), but limited evidence has been published in the literature regarding their occupational health issues (Davis & Kotowski, 2015). Nursing personnel have a higher incidence of WMSDs than other occupational groups worldwide and NAs are more at risk for WMSDs than other nursing personnel (Peterson, McGlothlin, & Blue, 2004). Those NAs working in nursing homes are especially at risk for WMSDs (Feng, Chen, & Mao, 2007; Pelissier et al., 2014). With an increasing aging population and shorter length of hospital stays, the demand for nursing home services has increased dramatically and become one of the fastest growing industries worldwide (Bureau of Labor, 2014; Social Welfare Department, 2017). However, WMSDs can negatively affect individuals, organizations, and society by increasing absenteeism, job tenure, functional disabilities, compensation and health costs, and reducing productivity (U. S. Department of Labor, 2016). Preventing WMSDs is essential to maintaining the health and well-being of NAs working in nursing homes and the quality of resident care.

On the contrary, a recent comprehensive review (Davis & Kotowski, 2015) of 132 articles found only 16 (12.12%) studies on NAs working in nursing homes compared with 90 (68.18%) studies on nurses in hospitals. P. Graham and Dougherty (2012) argued that NAs are more at risk for WMSDs than registered or licensed practical nurses because of their frequent lifting and transferring of physically demanding residents, yet they work low-wage jobs leading to little bargaining power in the health care system. The inadequate attention paid to NAs is reflected in the lack of research about WMSDs in this vulnerable working group. Furthermore, 103 (78%) studies of NAs used cross-sectional methods, mainly focusing on the lower back. More concerns now have shifted to shoulder and neck injuries (Luime, Koes, Miedem, Verhaar, & Burdorf, 2005; Meyer & Muntaner, 1999). However, qualitative details are missing in this body of quantitative literature (Feng, Chen, & Mao, 2007; Pelissier et al., 2014; Reme et al., 2014). Little is known about how NAs perceive the nature of their work in nursing homes and how their work contributes to WMSDs. The aim of this qualitative study was to address these gaps, explore NAs’ perspectives and experiences regarding the impact of WMSDs, and suggest interventions to reduce WMSDs. With this understanding, occupational health professionals could develop appropriate and effective WMSDs prevention programs for NAs working in nursing homes.

Method

This qualitative inquiry used focus group interviews to collect data. To understand NAs’ views about various working environments, purposive sampling was used to identify private (32%) and nongovernmental (NGOs; 32%; Social Welfare Department, 2017) nursing homes located in all three regions of Hong Kong: Hong Kong Island, Kowloon Peninsula, and the New Territories (Information Services Department, 2016). Furthermore, select nursing homes housed 70 to 200 residents, employed 10 to 50 NAs, and some had and others did not have lifting devices. Nursing assistants who were on duty when the researchers visited the nursing homes were invited to participate in focus group interviews voluntarily. The inclusion criteria included: (a) working as a full-time NA in the participating nursing home for at least 1 year; (b) providing direct patient care, such as turning, feeding, toileting, changing clothes, and changing incontinence pads; (c) being at the position of health worker, care worker, or other titles given by the nursing home; and (d) speaking Chinese.

Data Collection

Focus group interviews with five to seven participants each and one group per nursing home were conducted in March and April 2014 by the two researchers (S.S.Y.C. and K.C.) and two research assistants. The interviews were conducted with NAs working the day shift using quiet rooms in the nursing homes during staff lunch breaks from 13:00 to 14:30. A semistructured interview guide was adopted for the interviews (Sidebar). The researchers met participants, explained the study’s purpose, and reinforced the principles of confidentiality, anonymity, and voluntary participation. Written consent from each participant was secured prior to the 1-hour audio-recorded interviews. Field notes documenting the observations and impression of researchers were written immediately after the interviews. Ethical approval and access permission were granted by the University and the participating nursing homes, respectively.

Data Analysis

All interviews were transcribed verbatim in Chinese and imported into qualitative analysis software, NVivo 8.0, for data management. Conventional content analysis (Hsieh & Shannon, 2005) was adopted for data analysis, and categories were derived deductively from data. One researcher (X.B.L.) read the data word-for-word and line-by-line to derive codes, which were constantly compared during data analysis. Similar codes were combined, and new codes were added to accommodate new incoming data. Codes were then sorted into categories based on their relationships and linkages. Throughout the process of data analysis, one researcher wrote memos on impressions about the data and documented relationships between the codes as they emerged. The preliminary findings were discussed with the other researcher, and in case of discrepancy, this researcher reviewed and analyzed the data again before reaching consensus. Trustworthiness was ensured by peer debriefing between the researchers, providing an audit of data analysis and rich description of findings (Lincoln & Guba, 1985).

Results

The recruitment was completed, and data saturation was achieved after 24 NAs from four nursing homes were interviewed. Two nursing homes were private (Kowloon Peninsula and the New Territories) and two were NGOs (Kowloon Peninsula and Hong Kong Island). Among private and NGOs, each had one nursing home with about 200 residents and 10 to 15 NAs; the other nursing home housed 80 to 90 residents and employed 30 to 40 NAs. All nursing homes had lifting devices except one small private nursing home.

All participants (N = 24) were female with a mean age of 49.46 years (SD = 3.16). Over 54% (n = 13) and 37.5% (n = 9) had secondary education or primary education or less, respectively. Participants’ mean working experience in their current nursing homes was 9.26 (SD = 6.07) years with a range from 1.08 years to 20 years. Over 79% (n = 19) of participants indicated they had received lifting and transferring training, but the length of training ranged from 1 to 64 hours with a mean of 15 hours (SD = 15.63).

NAs’ Work

The participants’ work was mainly taking care of the daily needs of residents, including changing positions in bed to promote resident comfort and prevent pressure sores, and maintaining their personal hygiene. Transferring and lifting residents was one of the most commonly performed procedures. One participant said, “We transfer the residents out of and back to bed for breakfast, bathing and lunch. Thus, we transfer them for at least six times in one shift” (No. 2-1). Some participants were required to escort residents to hospitals, and perform other types of work such as cleaning floors and furniture, disposing of garbage, ironing and folding clothes, delivering meals, and lifting and moving equipment from one place to another. The workload of NAs was described as “overwhelming” by all participants. They were assigned on rotation to morning, afternoon, or night shifts. During a day shift, the participants worked 8 to 12 hours (NGO nursing homes scheduled 8- to 9-hour shifts and private nursing homes scheduled 10- to 12-hour shifts). Some of the participants who worked in nursing homes with inadequate staff were also required to extend their work hours to 14 hours per day or required them to work on their scheduled days off.

Besides physical demands, participants also experienced psychological stress. One participant said, “Some residents and relatives are demanding” (No. 2-3); other participants said, “When there is any problem in communication, they launch complaints on us” (No. 2-7); “these are invisible pressures on us” (No. 2-4). Some participants also experienced psychological distress as a result of witnessing residents’ suffering. One participant elaborated,

There is much sorrow in life. . . . A daughter visited her mother every evening. But she did not come for one week because of having a stroke and is now lying on the bed opposite to her mother . . . I worked here for more than ten years and witnessed hundreds of elderly moving in and “going back home [died]. We do not know what will happen tomorrow. Our mood is low. (No. 1-6)

WMSDs

Work-related musculoskeletal disorders were commonly reported, and participants stated that the problems were “occupational diseases” and “injuries all over the body” (No. 3-4). Low back and upper limb (i.e., hands, wrists, and elbows) pain and soreness were the most common followed by neck, feet, knees, and shoulders. One participant (aged 50) said, “As I am getting older, I feel pain in the wrist, fingers and lower back almost every day” (No. 3-4). Furthermore, “discomfort” was classified as one of three types: muscular soreness and strain, pain in sprained joints, and referred nerve pain or cramp. The pain in participants’ joints limited their movement and strength. Participants said, “I have knee pain as I squat and stand up very often. I also have pain in my ankles as I keep walking without rest for ten hours each day in the past ten years” (No. 1-2); “My wrists were powerless sometimes” (No. 2-6). Furthermore, one participant reported referred pain in one arm, which she thought was related to a neck problem. Two participants mentioned that their fingers spasmed when they exerted force. “Sometimes when I pulled the pads out, my hands twitched” (No. 1-2).

The Relationship Between WMSDs and NA Work

All participants believed that their musculoskeletal disorders were associated with their work. One participant said, “As we work as a NA, we repeat some body movements and exert force for many times each day . . . result in ‘wear and tear’ of the tendons and bones” (No. 2-6). Surprisingly, the participants believed it was inevitable to have musculoskeletal disorders when working as an NA. One participant said, “It is inevitable, even you are very careful, you will get hurt eventually. After all, you do the same work all the time” (No. 4-3).

Turnover leading to staff shortages, heavy workloads, limited space, new NAs, high resident dependency, lack of prework training, and limited maintenance of equipment were associated with NAs’ musculoskeletal disorders. Turnover resulted in a series of potential risks to the NAs. One participant said, “Many NAs quit their jobs because they cannot bear the tough work” (No. 1-5). Heavy workloads are another risk factor. “If there is a delay in completing bathing of the residents, the time for breakfast, feeding and changing diapers will be further delayed” (No. 1-3). Tight work schedules resulted in “We don’t use the equipment because the schedule is very tight. We need to save time” (No. 2-1). When too few NAs were on duty, the participants occasionally transferred the residents alone instead of with a coworker; the NAs also needed to work longer or continued working even though NAs with WMSDs were not fully recovered.

Lack of space was another commonly mentioned factor, particularly in private nursing homes. For instance, a number of beds are placed adjacent to room walls, so two NAs could not stand on either side of the bed to transfer residents. In addition, the space between two beds was limited, so participants could not adopt a broad stance to transfer residents. “We cannot perform the manual handling as taught because we need to work fast and the space between the beds is limited” (No. 1-6). Lack of space also prevents NAs from using mechanical lifting devices (e.g., hoists or lifters) and height adjustable bath trolleys, which allow NAs to bathe the residents lying flat at a comfortable height (Labour Department, 2000). One participant said, “The bathroom is too small for using a bath trolley” (No. 1-6). In another small private nursing home, the participants lifted and transferred residents up and down a narrow staircase every day.

Coworkers were a risk factor that emerged from the interviews especially when they were new to work. One participant said, “It is easy to be injured when transferring a resident with a new partner. I have to do the transfer on my own since the partner does not know how to cooperate with me” (No. 1-4). Moreover, the participants wanted to protect new staff and this added to their burden. One participant said, “Many of the new NAs are older . . . sixty-two. An old lady takes care of old ladies (residents). Others may be young nursing students working part-time in here. We worry about causing injury to them” (No. 1-5).

Resident dependence and cognitive ability were also risk factors for musculoskeletal disorders. The participants noted that the average age of residents was increasing in recent years (No. 2-4). When the residents were overweight, unable to cooperate or follow instructions, or acted aggressively, the NAs were at increased risk of injury. One participant said, “When residents are weak and feel like falling during the transfer, they hold on us tightly, scratch or even bite our arms. Thus, we often have bruise marks on our limbs” (No. 1-6).

Although training programs were provided, prework training was not adequate, especially in private nursing homes. One participant said, “I hurt my back on the second day of work when I changed a diaper for a resident. I hadn’t received any training at that time” (No.4-4). In addition, some NAs did not participate in training programs because the training schedule interfered with their work schedules.

The participants acknowledged that equipment could facilitate their work to some extent. However, the manually operated equipment and maintenance might cause additional problems. One participant, from a nursing home with limited equipment, said,

We usually manually turn the handle to change the position of the bed when turning residents. Since some movable parts of the bed are not well oiled, I feel the tension on my neck muscles when my right hand exerts force to turn the handle of the bed. (No. 1-5)

Impact of Musculoskeletal Disorders

Fatigue is the most common impact of musculoskeletal disorders on participants’ daily lives. Participants said, “In fact, we all are very tired. We have the energy and motivation while taking care of the residents. When we get off work, we are just like a ‘dead dog’” (No. 1-3), “Our legs are so tired that they are not under control when we walk” (No. 2-6), “My son always sees me lying on the bed doing nothing” (No. 1-6). One young participant stated that she was too tired to play with her son. Another participant said, “Sometimes I yell at my husband angrily. I had to do all the housework after work. He didn’t help me” (No. 4-2). Participants also mentioned having difficulty falling asleep (No. 2-2) and waking up easily (No. 2-6) because of the pain. Rest was a strategy participants used to recover from fatigue. Some participants tried to rest during the work day even though no breaks were scheduled. One participant said, “We could have a short rest when the residents sit in the garden” (No. 4-5). Others relaxed by using massage chairs, engaging in relaxation exercises, or scheduling social gatherings after work. The participants also arranged household work to increase rest time. One participant said, “We neglect everything but just rest at home after work. We used to clean house every day, but now I only do it when it is very unbearable” (No. 3-3).

When participants had musculoskeletal disorders, some used analgesics on the injured part (e.g., ointment or plaster; No.1-3) or Dit Da Jow (No. 2-3), a Chinese liniment for healing bruises or relieving muscle pain. One participant also took supplements (i.e., bǔ gǔ wán) for joints (No. 2-7). Participants only sought professional care when the problem was too severe to tolerate (e.g., brief advice from the physiotherapist in the nursing home or physicians practicing Western medicine and Traditional Chinese medicine [TCM]). One participant said, “I will consult the doctor when I cannot get up from the bed to go to work” (No. 2-2). Several TCM treatments were used, including TCM massage, cupping, and acupuncture. However, NAs seldom took sick leave. Participants said, “We apply for sick leave only when we can’t exert force in limbs. We can’t rest too long” (No. 1-4), “We need to work and earn our living” (No. 1-3). Some participants resumed work even though time off from work was recommended by physicians. One participant said, “We do not want our colleagues to stretch themselves to the limit so as to take up my work . . . I will come back to work if I can walk” (No. 1-6).

Suggestions to Reduce WMSDs

Despite the physical demands and psychological stress of NA work, many of the participants were committed to their work. One participant elaborated on the reasons: “I am not afraid to say . . . we are motivated to stay in this job because we are concerned about our residents. One cannot take this job if they are impatient or not caring” (No. 3-4). Participants suggested interventions and strategies to reduce WMSDs. In terms of equipment, the participants from the nursing homes which were not well equipped suggested replacing manual beds with electric beds, and purchasing chairs with wheels to reduce the frequency of transfer and lifting. Participant also addressed nursing home limitations: “Ceiling hoist is good but it may not be applicable because of the small space and suspended ceiling” (No. 1-3).

The participants also thought workplaces could be rearranged. Participants employed in private nursing homes requested that shower equipment (e.g., commodes with rusty wheels) could be repaired. Some participants from an NGO nursing home suggested additional staff so that when someone was on vacation or sick leave, their work need not be shared by the other NAs on duty (No. 3-4). The participants in another nursing home suggested lunch breaks in a quiet room and short breaks in the middle of the shift. In this nursing home, the participants were required to take care of the residents when necessary during their lunch breaks. Some suggested assigning 10 minutes before work to stretching together. Another participant had a creative suggestion, “It is good for us to teach the residents to do some exercises and we all can stretch and shake our hands and feet” (No. 1-5). The participants also hoped they could have more staff on a regular basis.

Training was welcomed by the majority of participants. Some stated that at one time Tai Chi classes were offered to NAs in the nursing home but not many of them could attend due to days off or working the night shift (No. 1-2), and “because of knee pain, I failed to follow the movements” (No. 1-5). Participants were interested in transfer and lifting skills, strategies for preventing injuries and relieving musculoskeletal discomfort, stress reduction, relaxation methods, and social gatherings among NAs. The participants also suggested training new NAs before they start working.

Discussion

The findings of this qualitative study suggest that NA work, either at private or NGO nursing homes, well equipped or not, was overwhelming and involved resident and nonresident job tasks. Furthermore, manual lifting and transferring of residents was viewed as unavoidable even though lifting devices were available. Work-related musculoskeletal disorders affected a variety of body parts (especially upper and lower limbs) rather than being limited to the lower back. Furthermore, the risk factors for WMSDs (i.e., physical, psychosocial, organizational, and personal factors as well as coworkers and residents) were described by the NAs as multifactorial. Work-related musculoskeletal disorders had a negative impact on both their work and personal lives.

Strengths and Limitations

Although WMSD risk factors have been reported quantitatively through cross-sectional studies (Eriksen, Bruusgaard, & Knardahl, 2004), NAs’ dynamic work conditions and their effects on WMSDs could only be vividly portrayed via a qualitative study. For instance, long work hours have been reported in quantitative studies. However, NAs not only work long hours, they even take care of residents during their meal times. The frequency and reasons for sick leaves are not well described in quantitative studies because NAs continue to work even after they are granted sick leave. Thus, it is the synergistic effects of long work hours without sufficient rest, working with musculoskeletal pain because of staff shortages, ineffective management that offers insufficient prework training and inadequate equipment maintenance, and an aging workforce with strong commitment to resident care that contribute to WMSDs among NAs working in nursing homes.

Although the findings of the study reflect the experiences of NAs, the study has its limitations which include the adoption of a cross-sectional design in interviewing participant NAs. Recall bias and the outcome of events may have affected their responses.

The Synergistic Effect

Worldwide, long work hours, particularly in health care, has been a concerning trend (Ball, Maben, Murrells, Day, & Griffiths, 2014; Trinkoff, Le, Geiger-Brown, Lipscomb, & Lang, 2006) and identified as a risk factor for WMSDs. In their review, Ball et al. (2014) found that working 12-hour or longer shifts could lead to WMSDs for staff and other adverse effects on staff and patients. Besides shift length, WMSDs were also significantly associated with less than 10 hours between shifts, and working while sick, on days off, or during breaks (Trinkoff, Le, et al., 2006). In Canada, a 12-hour shift pattern includes 3-day 12-hour day shifts with 2 days off and then 4-day 12-hour night shifts with 3 days off. It is recommended to have a rest period of at least 24 hours after each set of night shifts (Canadian Centre for Occupational Health and Safety, 2016). However, it has been found that this recommendation is not always implemented; about 29% of registered nurses worked 12 or more hours per day but 14% worked 50 or more hours per week and 5.6% worked 6 to 7 days per week. Furthermore, about 20% of registered nurses work more than one job (Trinkoff, Geiger-Brown, Brady, Lipscomb, & Muntaner, 2006). Similar findings were reported for NAs because they earn lower incomes than registered nurses. In addition, current findings from 71 cities worldwide indicated that Hong Kong has the longest weekly work hours (50.11) with short annual leave (17 days) compared with global averages of 36.31 work hours and 23 days of leave (United Bank of Switzerland, 2015).

Fatigue is the inevitable consequence of long work hours (Labour Department, 2008). Based on Grandjean’s (1998) fatigue and rest framework, fatigue is defined as muscular fatigue with localized muscle pain or general fatigue with an unwillingness to work and a need for rest. General fatigue is gradually produced from an accumulation of stressors during the course of a day until workers want to stop working and rest. However, for committed NAs, this feeling is disregarded and NAs continue working until fatigue is overwhelming. Overcommitment has also been identified as a risk factor for WMSDs (Pelissier et al., 2014). Even after working long hours, NAs are required to work the next scheduled shift. Adding to this dilemma is the shortage of NAs, a worldwide issue. In the United States, 2.3 million NAs will be needed to meet demand over the next decade (J. Graham, 2014). In Hong Kong, it is estimated that at least 5,000 NAs are needed to care for the aging population (Legislative Council of the Hong Kong Special Administrative Region of the People’s Republic of China [LCHK], 2013). To compensate for this shortage in the United States, NAs may work more than one shift a day and more than 40 hours a week (Hagerty, 2013). The results of this study further found that NAs with musculoskeletal pain, even with sick leave benefits, continue to work because they do not want to add to their coworkers’ burden and they need the additional wages. However, NAs working in nursing homes are generally older; one fifth of NAs are 55 years or older (Hagerty, 2013). The participant quote, “old NAs take care of old residents” (No. 1-5), reflects the work situation in nursing homes. Thus, it is not surprising to hear from study participants that they experience muscle pain and lack energy to do anything after work. They just preferred to lie down and rest. Without adequate rest, NAs are vulnerable to WMSDs.

Clinical Implications and Future Studies

Although the work of NAs is demanding, the study findings revealed that study NAs were a caring group who supported their colleagues. They were committed to and responsible for their residents. Strategies to retain these workers and attract new staff who practice with compassion, especially young people, in nursing homes are a primary issue faced by nursing home administration, policy makers, and researchers. Some strategies were suggested by NAs in this study (e.g., upgrading equipment from manual to electrical, reorganizing work to provide regular breaks, and exercise with residents to reduce the risk of injuries). The review of literature found that although NAs are more likely to suffer WMSDs than other nursing personnel, limited intervention studies have been conducted on this vulnerable group worldwide. Intervention studies conducted among other nursing personnel can be used as a reference for developing effective programs to reduce NAs’ WMSDs. Several systematic reviews have commented that single interventions (e.g., stand-alone manual handling or ergonomics training, stress management, or lumbar supports) are not effective, and that multidimensional intervention strategies are necessary to address all aspects of nurses’ work that may contribute to WMSDs (Nelson et al., 2006; Peterson et al., 2004). More studies on NAs working in nursing homes should be conducted regarding job evaluations, job rotations, and work hour assessments. It has been proposed that multidimensional intervention strategies should include elements of engineering and administrative controls as well as training and education (Nelson et al., 2006). Administrative support is paramount in changing shift patterns, purchasing lifting devices, maximizing space, designing prework training, establishing a safety culture, and providing incentives to attract new NAs. Multidimensional programs that reduce nurses’ WMSDs should include a combination of ergonomics, patient handling, stress management, lifestyle management, risk assessment, back injury resource nurses, state-of-the-art equipment, and no lift policies (Nelson et al., 2006; Szeto et al., 2010). These requirements are consistent with the occupational health and safety literature and the results of this study, which demonstrated that WMSD causation is multifactorial.

Conclusion

To summarize, WMSDs, which involve a variety of body parts, not only the lower back, are common among NAs working in nursing homes. Their aging bodies are overworked without adequate rest between shifts because of long work hours, staff shortages, heavy physical demands, and intensive psychosocial stress. Furthermore, their responsibility to the residents and their coworkers support working with musculoskeletal pain rather than taking sick leave. Unfavorable working environments with limited space and inadequate lifting devices and equipment maintenance further increase their risk for WMSDs. Multidimensional intervention strategies should include elements of engineering, administrative, and personal controls to reduce WMSDs among NAs working in nursing homes because identified modifiable risk factors are multifactorial.

Applying Research to Practice

The dynamic work conditions for NAs working in nursing homes should be analyzed to determine their effects on the incidence of WMSDs. This qualitative study found that it is the synergistic effect of long work hours without sufficient rest, working with musculoskeletal pain because of staff shortages, ineffective management, insufficient prework training, inadequate equipment maintenance, and an aging workforce with a strong commitment to resident care that contributes to WMSDs among NAs. Only multidimensional intervention strategies including elements of engineering, administrative, and personal controls can reduce this synergistic effect.

Sidebar: Interview Guide (English Version)

1. Based on your work experience in nursing homes, how do you view your work?

2. Do you have any musculoskeletal problems?

3. How do you view the relationship between your musculoskeletal problems and your work in the nursing home?

4. What are the strategies used in your nursing home to reduce musculoskeletal problems?

5. What kind of resources can the nursing home provide to reduce musculoskeletal problems?

6. Has your daily living or habits been affected by musculoskeletal problems?

7. Do you have any measures to relieve musculoskeletal problems?