What are the risk factors associated with lower back pain amongst nurses?

What are the risk factors associated with lower back pain amongst nurses?


The purpose of this assignment is to review chosen literature on recognising the risks factors of lower back pain in nurses. This will then enable the author to establish what impact these implications have on nurses. Work factors was chosen as the subject to review as this was quite a problematic issue that the author found on a recent placement.

Dawidowicz (2010) defines a literature review as a “systematic examination of knowledge available from a chosen topic, including appropriate peer- reviewed sources”. Furthermore, a literature review should be a “review of what’s known, not suspected or assumed about a specific topic. Therefore, It’s goal is to complete an “accurate representation of the knowledge and re- searched based theory of the chosen topic”.


Recent evidence and research has shown that, over recent years lower back pain has become one of the highest causes of work related illness (Beijia et al, 2005). Wolfe & Pfleder (2003) therefore suggest that, this is very serious issue and a costly matter to hospitals and trusts. Bernard (1997) further goes on to say, it is shown that lower back pain and workload are related through research taken through recent years. Collins & Menzel (2006) state “The Health of nurses influences not only their job satisfaction, quality of life and desire to change careers but also quality of care and patient safety”, therefore, many occupational Health teams have become aware and therefore, are now focusing on the nursing profession, as it is identified as physically and psychologically demanding.


In order for the literature review to begin surrounding this subject, the author had to search databases, generating from the University of Derby, through their EBSCO database. This therefore enabled the author to search, Medline, British Nursing Index and chanhai were searched for the relevant articles. The author also searched reference lists from systemic reviews for the chosen subject. In order for the author to get the best results from the database, a technical support technician helped ensure that important literature was included in their search.

The key words searched in this literature review were, “back pain”, and “work related” the author had to limit their criteria, in order for the search to work. The author decided that for particle reasons and also for up to date evidence on the subject, a timeline search was to be used, this was “1990-2011” which resulted in 792 articles being found. The literature search was still to wide with resources, therefore, results had to be narrowed down more, in order to do this the author searched using the advanced search. This was used so that the “Gender” search was male and female, “language published” was English. The author also considered the age of the participants in the search, they searched the age criteria as, 19+, middle aged and 65+. This generated 103 articles, however, the author still considered this to be to wide a search. Lastly, the subject search then included “Nurses” which then resulted in sixty-one articles being found. The author searched “all world” in order to get the best possible results from the search and to compare whether each country has the same outcome of different. The chosen articles ranged from, USA, Greece, South Korea, Canada, Netherlands and Norway. The author wanted to compare and contrast other countries aspects on the risk factors for lower back pain through the work environment.

The author then read through the article titles generated from the search from reading the articles abstracts: the author the put them in order or relevance. However, from further reading, the author found most article un-relevant to the topic and, the language was not English. Therefore, the non relevant topics and, articles that did not provide the minimum information required. were then removed from the search. The author found relevant articles, however, they were not available from the university and although stated therefore, the author had to exclude this from their list. This then left thirty articles which, the author thought were expectable by reading the abstracts. From the thirty articles, 15 were actually deemed suitable from further reading of the articles.

The results then left seven articles to be reviewed by the author, these were written by; Simon et al. (2006); Vieira et al. (2006); Ja June et al. (2009); Eriksen et al. (2004); Bryns et al. (2004); Alexopoulos et al. (2003). These articles have been chosen due to the fact they have been peer- reviewed and contain useful and relevant information on the subject and are ethically approved by the participants in the research. The articles ranged from credible sources, these were: International Journal of Nursing Studies; Advanced nursing practice; Journal of clinical nursing and journal of occupational and evoirmental health. The articles explore issues around Lower back injuries and pain in the working environment for nurses, including not only physical factors but, also psychophysical factors. The articles explore why risk factors are there and how in future they can be preventative through education mandatory training.


The table (below) has been drawn up through the guidance of PRISMA (2009) to extract the useful and relevant information out of the articles. The author has chosen to present the findings in a table ,as it enables them to review, abstract and reference the appropriate and important information needed for the literature review.

Table 1: results from the chosen literature

Author & Year originStudy Selection Age of participantsStudy CharacteristicsMethodologySummary Of Findings
Simon et al. (2006)Belgium; Germany; France; Italy; The Netherlands; Poland; Slovakia21,516


To what extent physical and psychosocial risk factors are associated with
back-pain-related disability in nursingCross-sectional secondary analysis of multinational dataManual handling not the cause of lower back pain problems
Vieira et al. (2006)Canada47


To identify problems leading to the higher incidence rate of work-related low back injury among nurses in the orthopedic and intensive care unitHospital injuries records and questionnaireManual handling concerns:
Environmental factors
Ja June et al. (2009)South Korea1345


To examine the prevalence and treatment of low back pain and the relationship to personal and work-related characteristicscross-sectional and included a survey of ICU nursesShift patterns
Manual handling
Eriksen et al. (2004)Greece351


To explore work factors that predict intense lower back pain and lower back pain in relation to sick leave.
Factors associated with lower back painQuestionnaire surveyHow nurses transfer patients
Heavy lifting
Work demands, shift changes, lack of support
Bryns et al. (2004)Illinois, USA4826


Risk factors related to lower back pain in nursesSurvey, self questionnaireShift work
Heavy lifting
Physical workload
Patient transfer
Alexopoulos et al. (2003)Norway



To investigate between the physical and psychos social characteristics of lower back painQuestionnaire survey at 3 month and 15 month intervalsHigh job demands
Physical workload


From evaluating the articles, the author found that, the most common theme for risk factors showed that, areas surrounding physical workload, work demands and nurse education and patient transfer. These were persistent and have been considered the most important areas to focus on the literature review.

Physical workload

There were six articles that showed the association of the risk of lower back pain through physical workload of the nurses. Vieira et al. (2006) found in his study that, by using a body part discomfort index and, Borg rating of perceived exertion, they were able to assess where the common risk factors were among the nursing staff. The study found that, the more patient transfer, lifting and pulling increased the percentage of lower back pain incidence. Nurses reported in the study that manual handling was the most stressful and energetic part of their workload, consisting of 60% of the participants complaining of back ache or pain at the end of their eight or twelve hour shift. Vieira et al (2006) studied that, most of the shifts consisted of the nurses to bend squat, lift and twist, he found this was the cause of all most cases of lower back pain. Eriksen et al. (2004) conducted a search consisting of 4266 at three months and then fifteen months later reducing to 3808 nurses. The research showed that, nurses positioned the patients a average of five- nine times per eight hour shift. The author feels that this is a frequent occurrence throughout the studies done. Therefore, Eriksen et al (2004) also found that frequent heavy lifting was a strong association of lower back pain related sickness. In the present study, it identified the frequency of lifting, carrying, and pushing heavy objects showing a high relevance and predicted high intensity of lower back pain in the nurse’s. Bryns et al. (2004) conducted a study that showed 4826 nurses and the fear of them developing lower back pain and possible problems. It was shown that physical workload was evaluated through job category, it highlighted the importance of the different nursing roles and how much physical workload they dealt with in a twelve hour shift. The study conducted showed that again lifting and patient transfer was one of the highest risks to lower back pain. Furthermore, a point made by Bryns et al (2004) was job location and position, which showed more strenuous patient transfer, therefore highlighting more lifting and more years working in that area, produced the highest risk factors with reported lower back pain. Ja June et al. (2009) is keen to emphasis that in their study the nurse’s were at young age resulting in the mean aged being only twenty-seven. Nevertheless, nurses in South Korea are portrayed as being healthy with little health problems or suffer with back problems (Smith et al. 2004). However, nurses were found with a high prevalence of back pain resulting from physical work demands in the shifts. A valid argument to make is that, although south Korea have the lowest age range compared to the other studies carried out, the risk factors were much the same as with older more experienced nurses. However, Simon et al (2006) comprised a search; they found that in their study, manual handling was not a major concern for the risk factor of lower back pain. The search reported that they used a two scale “lifting and bending” score that established the percentage of nurses suffering with their back at the end of their shift, however even though the study showed a high percentage of nursing staff with lower back pain, Simon et al (2006) concluded they found no association between the two.

Work environment

five of the articles emphasised the work demands of the nurse’s. The studies picked up on shift patterns and co-worker support. Research by Lagerstrom et al. (1998) identifies that, shifts are risk factors for lower back pain. It’s highlighted that day shifts nurses perform more patient handling, resulting in higher physical work demands than on night shifts. This is reviewed in a study done by Ja June et al. (2009) who explains that work demands play a vital part in the exposure of risk factors of lower back pain. However, it was shown from the study that the nurses in Ja June et al (2009) study who worked night shifts, had a higher rate of lower back pain than day time nurse’s. Therefore, the association was shown to be, night work decreased sleep time and quality, and this sleep disturbance caused muscle strain. The author feels that nurse staffing levels were an important issue raised in relation to night shift, Ja June et al (2009, pp 484) state in their study ”Nurse staffing that is not adequate was associated with a higher back pain prevalence than perceiving staffing that was adequate“. The study showed that, night shift nurse’s had fewer numbers working compared to day shifts, resulting in more physical work demands. It has become apparent in a study by Eriksen et al (2004) that in their search that the association between night work and lower back pain were high than those who never worked a night shift. This could result in the nurses being left alone on night shifts, therefore leaving them lifting or doing heavy patient transfers alone (Eriksen et al, 2008). It was also reported by nurses in the recent study that, low co- worker support were considered to be a high risk to them, not being supported and insufficient staffing levels were a big concern. Alexopoulos et al (2003) study found the association between high job demands, low job control and lower back pain. The study showed that, nurses needed recovery time to help relieve them from the strenuous shifts, however, it was shown that this was not done and, nurses carried on to do the work of others who were on sick leave or annual leave. It was conducted that due to the hospital size, the turnover of patients were demanding, resulting in work pressure on the nurses. Ja June et al (2009) agrees with Alexopoulos et al (2003) study and cites, regardless of length of shifts and shift work demands, it identifies that, it is a risk factor for lower back pain. They further state that, this should be examined in more depth in the future to conclude how much a risk factor it really is on nurses.

Nurse education and patient transfer aides

The author has found from the beginning of reading the research articles, that it has become apparent the association of lower back pain and manual handling, showing nurses, did not use the manual handling equipment supplied to them. Bryns et al (2004) study acknowledges the fact that, nurses did not follow the correct safety procedures when manual handling of patients. Therefore, they decided that they would use a knowledge scale taken from the Back Prevention Agency and incorporated this into the study to understand how well the nurses understood back safety issues. The Health Belief Model states that “Nurses need the basic knowledge of back safety and, must be aware of certain risks to be able to feel venerable to risks in order to become motivated to be aware of a safer behaviour”. Bryns et al (2004) report consequently showed that from their study, 11% of the nurse’s use the manual handling aides provided for them. However, the remaining percentage used other forms of manual handling that was considered to be a risk to them. Furthermore, the study emphasised and made a point that, the nurses understood about back safety measures; however, 46% of the nurses blamed the environment for the reason of awkward space and room sizes. 56% of the nurses blamed themselves and the environment for not correctly doing manual handling. Therefore, The reason they did not follow the safety procedures were, it was quicker doing other forms of manual handling and the mechanical aides were unavailable at the time. Vieira et al (2006) study highlighted the fact that the nurses would pull the patients up the bed and do squat lifts rather than use mechanical lifting aides. In contrast, the study cited that this became a consistent problem towards lower back pain. Consequently, the study recognised that the nurses understood the importance of mechanical lifting aides, however, they did not use them throughout the study, which highlighted that they did not use the mechanical lifting aides due to the fact it took longer to transfer the patients, despite the fact that this could reduce the risk of lower back pain or serious back problems.


To conclude on the research, the author has found strong factors that are associated with lower back pain. Due to the word count for this literature review, the author chose the relevant topics to review in order to comply with the three thousand word limit. The significant factors showed that nurses had a great physical work demands, resulting in risk factors to occur. Evidence was produced by Simon et al (2006); Vieira et al (2006); Ja June et al (2009); Eriksen et al (2004); Bryns et al (2004); Alexopoulos et al (2003) that, heavy patients and awkward positions such as squats, twists and bends, nurses got in to for patient transfer became a significant factor that should be reviewed more in hospital departments. However, this can be argued by literature produced from both Bryns et al (2004) and Vieira et al (2006) that highlights that nurses are educated and trained for the correct safety procedures, yet fail to use manual handling equipment. The author feels that, this is a major problem and, therefore concerned that, if nurses carry on to work this way, back pain will become a greater issue and may result in disability. Therefore, education and training courses should be mandatory and be assessed frequently to improve the outcome. Furthermore, the underused of requirement should be investigated more to prevent back pain.

Work factors showed to be a significant risk to lower back pain. research has shown that nurses have tiring and strenuous work demands, resulting in lack of rest at the end of shifts. Research has also proven to show that shift patterns have a increasing effect on lower back pain and also co-worker support. The author feels that this should be addressed and more support put in place to support nurses on strenuous shifts in the future.