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Development of an intervention to prevent back pain in nurses and nursing students

Nurses report high rates of back pain with consequent disability, work absenteeism and attrition from the profession. In the current climate of an international nursing shortage, efficacious interventions to reduce the impact of back pain must be developed. It is uncertain what components a back pain preventive intervention should comprise. Appropriate and reliable means to assess back pain and disability in nurses is also undetermined. The first aim of this thesis was to undertake a mixed methods program of research to inform the development of an intervention to prevent back pain in nurses. The second aim of the thesis was to examine the psychometric and measurement properties of back pain and disability outcome instruments frequently applied in nursing samples. Epidemiological studies were undertaken to examine factors associated with back pain in nursing cohorts. In student nurses, a history of manual handling work was found to be significantly associated with neck and back pain outcomes. In a large population cohort study of nurses and midwives, pain characteristics (pain severity and radiation), pain-related cognitive and behavioural factors (kinesiophobia and passive pain coping), job characteristics (job classification and manual handling task frequency) as well as demographic interactions explained sick leave due to back pain. A systematic review was undertaken to determine the efficacy of interventions aiming to prevent back pain and back injury in nurses. Due to methodological heterogeneity, a qualitative synthesis of evidence was undertaken on the 16 studies that met inclusion criteria. The review identified moderate level evidence from multiple trials that manual handling training in isolation is not effective and multidimensional interventions are effective in preventing back pain and injury in nurses. Single trials provided moderate evidence that stress management programs do not prevent back pain and limited evidence that lumbar supports are effective in preventing back injury in nurses. There was conflicting evidence regarding the efficacy of exercise interventions and the provision of manual handling equipment and training. A qualitative description study was employed to explore the beliefs and perceptions of nursing stakeholders regarding risk factors for back pain and strategies to prevent back pain in nurses. Stakeholders identified individual, intrapersonal, organisational and environmental risk factors that were consistent with the social ecological view of health. They believed that interventions targeting the individual would be ineffective in the absence of workplace and other reforms. At the individual level, they recommended strategies that address physical, psychological and occupational preparedness for nursing work. In addition, they suggested ecological intervention strategies to induce change at the intrapersonal, organisational, community and policy levels. A mixed method synthesis of evidence was performed to develop an evidence-based and stakeholder-relevant intervention that aims to reduce the impact of back pain in nurses. The proposed intervention incorporates evidence-based multidimensional strategies that address individual and organisational level factors, and proposes ecological factors that may warrant inclusion once evidence of their causal association with back pain is established. Methodological studies examined the psychometric and measurement properties of key instruments used to assess back pain and disability in nursing populations. An extended version of the Nordic Musculoskeletal Questionnaire – that is frequently modified when applied in nursing cohorts - was developed and deemed to have acceptable test-retest reliability. The Oswestry Disability Index was found to have unacceptable measurement properties for application in nursing samples, and is therefore not recommended for future studies of back pain related disability in the nursing population. In summary, this program of research contributes novel insights that can meaningfully inform understanding of back pain prevention in nurses. Factors not previously assessed in nursing populations have been examined and shown to be significantly related to back pain outcomes. The strength of existing evidence for the prevention of back pain and injury in nurses has been established, and methodological advances regarding appropriate and reliable measurement of back pain and disability have been made. The views and perceptions of stakeholders from multiple levels and vantage points have been considered and integrated within the interpretation of evidence from multiple mixed method studies. In fact, stakeholders have played a crucial role in the identification of an appropriate theoretical framework – the social ecological paradigm - to conceptualise back pain causality in nurses and identify relevant solutions. A future research agenda of expanded scope is implicated to adequately address back pain prevention in nurses.