Lower back pain and other musculoskeletal disorders are common across the ages and account for significant disability globally. They also contribute to the global burden of diseases through disability–adjusted life–years (DALYs) lived (GBD 2019 Diseases and Injuries Collaborators, 2020). It is estimated that 20.3 million people are affected in the UK, with more women affected (11.6 million) than men (8.7 million), of whom 10.2 million are aged 35-64 years and 7.4 million are aged over 65 years (Versus Arthritis, 2021). In the UK, nearly two in every ten people aged 16 years and over have reported having a long-term musculoskeletal condition, with 10 million having back pain (Versus Arthritis, 2021). There is also evidence of a deprivation gradient and ethnic variations, with those in the most deprived quintile, as well as Caucasians and Black Caribbeans having more long-term musculoskeletal conditions (Versus Arthritis, 2021).
According to the 2020/21 Labour Force Survey, 470 000 working people experienced work-related musculoskeletal disorders, with 45% being affected by upper limbs and neck issues, while 39% were affected by back issues (Health and Safety Executive (HSE), 2021). Before the pandemic, the rate of self-reported, work-related musculoskeletal disorders was showing a small downward trend, with the 2020/21 rate being broadly similar to the 2018/19 rate. However, there is a consistent gradient of higher rates of work-related musculoskeletal disorders reported by both men and women aged 45 years and over compared to those aged 16-34 years. Higher rates of musculoskeletal disorders are reported in construction, and health and social care, with health professionals reporting statistically higher rates of musculoskeletal disorders (HSE, 2021). Manual handling, working in awkward or tiring positions and keyboard or repetitive work were cited as the main work contributors (HSE, 2021).
Musculoskeletal disorders which include back, neck and arm strains account for 40% of sickness absences in the NHS, and as such, are one of the most common causes of sickness absences which could lead to long-term absences (NHS Employers, 2019). Such injuries have long been recognised as an ‘occupational hazard’ in nursing which is why there is an emphasis on adopting sound moving and handling techniques during pre-registration nurse education and subsequently by all healthcare employers (NHS Employers, 2019). It is likely that community nurses working in clients’ homes will be at greater risk because they may have to work in poor ergonomic environments, not have access to the right moving and handling equipment and may have to adopt awkward postures in the space available within their clients’ homes.
‘There is a consistent gradient of higher rates of work-related musculoskeletal disorders reported by both men and women aged 45 years and over compared to those aged 16-34 years. Higher rates of musculoskeletal disorders are reported in construction, and health and social care, with health professionals reporting statistically higher rates of musculoskeletal disorders’.
Staff absence creates workforce shortages and have a direct impact upon both client care and staff experience. This potentially creates a vicious cycle, especially when there are workforce vacancies. In March 2022, the overall NHS absence rate for England was 6% which is slightly higher than February 2022 (5%) and higher than March 2021 (4%), with regional (highest in North West (6.6%)) and organisational (highest in Ambulance Trusts (9.1%)) variations (NHS Digital, 2022). Mental health conditions were the most reported reason for sickness absences and accounted for more than half a million full-time equivalent (FTE) days lost and 20.5% of absences in March 2022 (NHS Digital, 2022). The Health Foundation (2019) acknowledged that primary care and community services face significant challenges regarding recruitment and retention, highlighting the imperative of minimising sickness absence and ultimately making the NHS a comfortable place to work at and have a long-term career in.
Little is known about the musculoskeletal well-being of nurses working in the community and their engagement in preventative interventions as a distinct group. In early 2015, a small qualitative study of seven district nurses working for an integrated NHS Trust in central England reported stoical selflessness, workplace well-being engagement strategies and their priorities for promoting musculoskeletal well-being (Boniface et al, 2016). The small sample reported that they accepted that damage had already been done early in their nursing careers and musculoskeletal pain was part of their working lives. The participants recalled mandatory training rather than other well-being initiatives and expressed a preference for in-person workplace initiatives rather than emails. They described how treating clients’ legs and other caring activities in their clients’ homes made musculoskeletal wellbeing more challenging as access to kneeling, moving and handling equipment is not always easy and often only offered in response to a nurse developing a musculoskeletal problem. Like many healthcare professionals, they found it difficult to undertake physical activity as part of their daily lives.
The National Institute for Health and Care Excellence (NICE) (2016) recommends exercise and the continuation of normal activities for the management of lower back pain. The exercise may be biomechanical, aerobic, mind-body or a combination of these and may be taken in a group programme. The guideline does not recommend orthotics, manual therapies, acupuncture or electrotherapies. The recommendation of physical activity (exercise) is supported by Alzahrani et al's (2019) systematic review of 24 studies (n=95 796 participants) which revealed an inverse relationship between physical activity and lower back pain, suggesting moderate doses of physical activity may be beneficial for both its management and prevention.
The extent to which community nurses are able to undertake regular physical activity is unknown. Boniface et al's (2016) sample of seven district nurses reported difficulty in undertaking physical activity, while in Bakhshi et al's (2015) study, 75% of their single London site sample (623 registered nurses; 52 of whom worked in primary care/community) reported being physically active. Over a quarter (29%, n=156) of that sample reported undertaking moderate-intensity exercise for less than an hour daily and 7% reported undertaking moderate-intensity exercise between 1–2 hours daily. Similar to those studies included in Alzahrani et al's (2019) systematic review, these studies of nurses relied on self-reporting of physical activity which may reflect recall bias and over-estimation, and there was no attempt to measure occupational physical activity as distinct from non-occupational physical activity.
Understanding the musculoskeletal needs and well-being of community nurses is clearly a priority for healthcare managers, especially if staff absences caused by musculoskeletal disorders are to be minimised and community nurses are to enjoy healthy working lives.