Complaints of Nurses' Low Back Pain Assessed from Individual

Characteristics and Workloads

Dameria, Frans Judea Samosir, Putri Yunita Pane, Pahala M. J. Simangunsong, Putranto Manalu,

Perry Boy Chandra Siahaan, and Ulina Tarigan

Public Health Department, Universitas Prima Indonesia, Jl. Sekip, Medan, Indonesia

Keywords: low back pain, individual characteristics, workloads

Abstract: Complaints of low back pain often occur in health workers, especially among nurses who work in the

Emergency Room since they have a high work intensity. The purpose of this study was to determine the

relationship between individual characteristics and workload on complaints of low back pain among nurses

in the Emergency Room at the RSUP H. Adam Malik Medan. The research design used was an analytic

survey with a cross-sectional approach. The sample size of 30 respondents was obtained through purposive

sampling. The results of statistical tests using the chi-square showed that there was no relationship of

individual characteristics (body mass index 0,372; age 0,367; years of service 0,611) and the complaints of

low back pain. On the contrary, the workload had a significant relationship on the complaints of low back

pain (p-value of 0,001) among nurses at the RSUP H. Adam Malik Medan.

1 INTRODUCTION

Nurses are one of the human resources in the

hospital who have a large enough number and role in

determining hospital services. Nurses are classified

as a workgroup with a high risk of experiencing Low

Back Pain (LBP) or what is often described as lower

back pain due to daily activities in the hospital to

provide health services (Amila et al, 2015).

LBP is pain that is felt in the lower back where

the pain originates from the muscle, spinal (lower

back) area, nerves, or other structures around the

area. LBP can be caused by disease or abnormalities

in the testicles or ovaries. LBP can also be caused by

work factors; namely, work time, work mass,

workload, and a person's work environment factors

in the form of vibration and work climate (Suma'

mur, 2009).

Until now, LBP is the biggest medical expense

in several countries. LBP not only causes physical

problems but can also be psychological problems

such as depression due to the very high pain felt by

the patient (Shin, 2020). In Switzerland,

musculoskeletal disorders caused an economic loss

of 3.3 billion due to lost productivity and

absenteeism from workers. LBP health care for

direct medical costs account for 6.1% of total health

care spending in Switzerland (Nützi et al., 2017).

In carrying out their duties to provide services to

patients, nurses are required to have time and energy

to meet each patient's basic needs. Nurses have very

diverse activities, including doing medication,

lifting, moving patients, and helping patients to

mobilize (Sarwili, 2015). For a long time, nurses

often perform activities in a standing or walking

position. The rotation of the spine when the body is

bending is a factor in causing LBP disorders. This

work activity will indirectly endanger the health of

the nurses themselves, especially female nurses. The

risk of muscle complaints in women is more

significant than men. This is because

physiologically, women's muscle ability is indeed

lower than that of men (Rizka, 2012).

WHO (World Health Organization) states that

LBP is a work-related disease in the form of

musculoskeletal disorders that can reduce workers'

productivity due to insufficient body activity so that

low back pain is the leading cause of disability that

affects work and general welfare (WHO, 2013).

Several factors can cause LBP risk in nurses, namely

over 35 years of age, smokers, 5-10 years of work,

work position, obesity, and a family history of

musculoskeletal disorders (Astuti, 2007). Other

factors that can affect the onset of LBP disorders

188

Dameria, ., Samosir, F., Pane, P., Simangunsong, P., Manalu, P., Chandra Siahaan, P. and Tarigan, U.

Complaints of Nurses’ Low Back Pain Assessed from Individual Characteristics and Workloads.

DOI: 10.5220/0010292501880195

In Proceedings of the International Conference on Health Informatics, Medical, Biological Engineering, and Pharmaceutical (HIMBEP 2020), pages 188-195

ISBN: 978-989-758-500-5

include individual characteristics, namely body mass

index, height, exercise habits, years of work, work

position, and workload weight (Harrionto, 2007).

The weight of the load lifted, the frequency of

lifting, and the method or technique of lifting

weights can affect workers' health in the form of

work accidents or the emergence of pain or injury to

the back (Effendi, 2007).

Occupational Safety and Health Administration

(OSHA, 2013) explains that occupational diseases

are the result of injuries or illnesses that occur in the

workplace as a result of material pressure or

working conditions while doing work. The

prevalence of spinal complaints reaches almost 60%

of all occupational diseases in nurses. In the United

States, 85% of the population is in second place

when it comes to doctor visits because of symptoms

of musculoskeletal complaints in risky occupations.

Fortunately, complaints of back pain resolve for the

most part in 2-4 weeks (Hills, 2020).

Many workers from various countries were

reported by The ILO Report for World Day Safety

and Health at Work in 2005 about the issue that 30%

of these workers felt complaints of disease and

discomfort in the back area and experienced

musculoskeletal events. Data reported by the

National Safety Council (NSC) in the state of Israel

has a prevalence rate of back pain in nurses of

around 16.8%. In Australia, there are 87% or 813

nurses experiencing LBP. The cases in the United

States regarding the incidence of musculoskeletal

injury are 4.62 per 100 nurses per year (Kepmenkes

RI, 2010).

Based on data obtained from Health and Safety

Excutive (2014), the prevalence of LBP during the

last 12 months in 2013/2014 in Great Britain, there

were 310 cases of LBP, and an estimated prevalence

of new cases was 150 cases. According to the Center

for Control and Prevention (CDC) in the The

American Academy of Pain Medicine (2011), at

least 100 million American adults report pain

complaints. The highest cause is low back pain at

28.1%. Expensive LBP treatment depends on

geography and facilities. Lumbar MRI (Magnetic

Resonance Imaging) prices vary between $ 300 and

$ 2,500 with a national average of $ 894 (Reilly

jacob et al, 2019)

Riskesdas 2018 data shows that 6.5% of workers

have back injuries, 32.7% have injuries to the upper

limbs, and 67.9% have injuries to the lower limbs

(Kementerian kesehatan, 2018). The results of data

from the Directorate General of Medical Services of

the Republic of Indonesia (2006-2008) regarding

occupational diseases in 2005, 2006, and 2007, of

the ten occupational diseases, LBP complaints rank

first with the highest number of cases. Workers with

a work posture of carrying, pulling, and pushing

(manual handling) and lifting (lifting) are the leading

causes of LBP. About 25% of work accidents occur

due to manual material handling work, and about

74% of spinal injuries are caused by lifting activities

(Hastono, 2006).

Nutritional status is one of the causes of fatigue.

A person's nutritional status can be measured by

BMI. A workforce with good nutritional status will

have better work capacity and endurance, and vice

versa. In a state of malnutrition with a non-

ergonomic work position, it will interfere with work,

reduce productivity and body endurance so that it is

easy to catch diseases and accelerate the onset of

fatigue (Budiono, 2003). A person with excess

weight and body fat will put pressure on the spine

when holding loads so that it is easy to damage the

bone structure and a danger to the spine. This

statement is supported by Setyanigrum (2014)

research that shows there is an influence between

BMI and LBP with a p-value of 0.000.

Research conducted by Sakinah (2013) states

that the percentage of LBP in the age group less than

35 years who experience complaints is seven people

(26.9%) and those who do not experience LBP are

19 people (73.1%). The age group over 35 years

who share LBP complaints are 17 people (60.7%)

and 11 people who do not experience complaints

(39.3%). This is in line with research conducted by

Shieh et al (2017) where the complaints of LBP

increase with age. The majority of nurses in the 35

year age group experienced LBP as much as 75.5%

(37/49) and the 20-24 year age group as much as

65.2% (214/328) nurses. The results of statistical

tests from this study indicate that there is a

significant relationship between age and LBP

complaints on brick workers in the Lawawoi

Village, Sidrap Regency. As you get older, the

muscles' flexibility also decreases, making it easier

for muscle and joint stiffness to occur. In addition,

there is also a narrowing of the space between the

vertebrae, which causes the spine to become

inflexible like it was at a young age. This can cause

pain in the spine to the waist (Idyan, 2008). In fact,

80% of back pain affects people aged 20-55 years.

However, this complaint is not specific to this age

group, which means that back pain can occur due to

infection, trauma, or other specific reasons

(Movahedi et al., 2020).

The excessive workload can lead to over-

stretching of the muscles to reduce the immune

elements that are between the spinal segments.

Complaints of Nurses’ Low Back Pain Assessed from Individual Characteristics and Workloads

189

Workload and LBP incidence have a significant

relationship, where nurses with heavy workloads are

at 5.6 times greater risk of experiencing LBP than

nurses with moderate workloads (Karyati et al,

2019). Research conducted by Indriasari et al.

(2017) also stated the same thing where there is a p-

value of 0.032 <0.05, which means that there is a

relationship between workload and LBP of nurses in

the operation room of the RSUD Kota Yogyakarta.

Working for long periods of time has a greater

risk of experiencing LBP. This period of work is

closely related to physical abilities. The longer a

person works, the lower their physical abilities will

be. Physical ability will gradually decrease as a

result of work fatigue, and indirectly, the working

period will result in the contraction of muscles that

strengthen and support muscles continuously for a

long time. This is supported by Kurnia PD (2015),

showing that workers with a service period of ≥ 5

years are at a higher risk than workers with a service

life of ≤ 5 years, as evidenced by the p-value

obtained of 0.038 and research conducted by Shieh

et al (2017) showing as much as 78.8% prevalence

rate of nurses who experience LBP have a work

history of eight years or more.

Having excess body weight is the most

significant factor in health problems. As a result of

being overweight, it will also put too much weight

so that it is at risk of causing damage to the spine

and joints, which is a factor in LBP incidence. Based

on the statistical analysis test results by Widjaya and

Aswar (2012), there is a p-value of 0.011, where

there is a significant relationship between

overweight and complaints of LBP. Research by

Rochman et al (2017) states the same thing that

obese nurses have a 7.09 times risk of experiencing

LBP compared to nurses who have ideal body

weight.

RSUP H. Adam Malik Medan is a type a hospital

where in 2014, it was designated as a hospital with a

national referral system. Therefore, the number of

patient visits every day is very high, especially in the

Emergency Room (IGD) which is a department

dedicated to the care of seriously ill patients. Nurses

are required to be alert in carrying out their work to

handle patients, do multiple procedures and often do

night shifts which are part of the pressure of the

work environment. Emergency nurses are also

required to have physical strength and no mental

disabilities (Yang et al., 2020). Based on the initial

survey conducted on emergency room nurses

through interviews, it was obtained that nine out of

11 morning shift nurses often experience pain due to

the high workload. Even some nurses use corsets

while working because of the back pain they

experience. In one work shift, nurses can lift, move

patients, and assist patients in mobilizing more than

five patients, with the average patient being adults

with different body weights. Moreover, nurses must

be up and running for a long time to provide

emergency services.

Based on the above background, the formulation

of the problem in this study is how big the

relationship between individual characteristics and

workload on complaints of Low Back Pain in nurses

of RSUP H. Adam Malik Medan. This study aims to

determine the relationship between individual

characteristics and workload on complaints of Low

Back Pain in nurses of RSUP H. Adam Malik

Medan.

2 METHOD

Figure 1: Research process.

The type of research carried out in this study was

an analytical survey using a cross-sectional design in

which the independent and dependent variables were

directly examined at the same time. The population

in this study were 84 nurses at RSUP H. Adam

Malik Medan, consisting of 54 nurses in the

emergency room triage section of the first floor, 13

nurse workers on the second floor of the Verlos

Kamer emergency room, and 17 nurse workers in

the Intensive Care Unit section on the third floor.

The sampling technique was purposive sampling,

in which the research sample consisted of 30 nurses

who worked at the IGD RSUP H. Adam Malik

Medan. In this study, the inclusion criteria were

male / female 25-60 years old, working as a nurse,

and willing to be the research sample. The exclusion

criteria were nurses who were absent/sick and who

did not complete the questionnaire.

HIMBEP 2020 - International Conference on Health Informatics, Medical, Biological Engineering, and Pharmaceutical

190

This research was conducted by directly visiting

nurses in the ER and providing a questionnaire

equipped with a letter of approval that was signed by

the respondent and then filled in directly by the

respondent himself. Data collection was done by

filling out the LBP questionnaire with measurement

references using the Oswestry Disability Index

(ODI) method. The workload was seen from how

many times nurses mobilize/lift patients in one

working shift. It was said to be a heavy burden if

serving more than five patients, and less than five

patients said to be a light burden. The research data

were then tested using descriptive univariate

analysis and bivariate (chi-square) test with a

confidence level of 95% (∝ = 0.05) (Hulu and

Sinaga, 2019).

3 RESULTS AND DISCUSSION

Based on the gender frequency distribution of 30

respondents, the majority of respondents were

female, as many as 27 people (90%), and a minority

of male gender as many as three people (10%). The

frequency distribution of the respondents' Body

Mass Index (BMI) varies. The majority of

respondents had an abnormal BMI, namely <18.5 or

> 25, as many as 22 people (73.3%), and the

minority BMI with an average of 18.5-25 was as

many as eight people (26.7%). The frequency

distribution of the respondent's age group is as

follows: the majority of respondents are the group

with age more than 30 years, as many as 29 people

(96.7%), and the minority is the group aged less than

30 years, as many as one person (3.3%)

Based on the respondents' tenure, the majority

who have worked for more than ten years is 26

people (86.7), and the minority who have worked

less than ten years are four (13.3%). The frequency

distribution of the respondents' workload was: the

majority of those with a heavy workload of more

than five patients were 16 people (53.3%), and the

minority of respondents who had a low workload

were 14 people (46.7%). Based on the LBP of

respondents, the majority who experienced LBP

were 19 people (63%), and the minority who did not

experience LBP were 11 people (37%).

Table 1: The relationship of BMI and Low Back Pain

complaints.

BMI

Low Back Pain

P-

Value

Not

experienci

Experien

cing

Total

N % N % N %

Normal 4

57,

0,372

Not Normal 7

30,

Table 2: The relationship of age and Low Back Pain

complaints

Age

Low Back Pain

P-

Valu

Not

Experiencing

Experiencing Total

N % N % N %

Young 1 100% 0 0% 1 100%

0,367

Old 10 34,5% 19 65,5%

29 100%

Table 3: The relationship of the working period and Low

Back Pain complaints

Working

Period

Low Back Pain

P-

Value

Not

Experiencing

Experiencing Total

N % N % N %

< 10

years

2 50% 2 50% 4 100%

0,611

> 10

years

9 34,6% 17 65,4% 26 100%

Table 4: The relationship of workloads and Low Back

Pain complaints

Workloads

Low Back Pain

P-

Value

Not

Experiencing

Experiencing Total

N % N % N %

Low 6 100% 0 0% 6 100%

0,001

High 5 20,8% 19 79,2% 24 100%

Complaints of Nurses’ Low Back Pain Assessed from Individual Characteristics and Workloads

191

3.1 The Relationship of BMI and Low

Back Pain Complaints

Based on table 1 above, the value of p = 0.372 (p

value> 0.005) is obtained, so Ho is accepted so that

it can be concluded that there is no relationship

between BMI and LBP complaints among the

emergency room nurses at H. Adam Malik Medan.

The reason why BMI is not related to LBP

complaints is because the majority of respondents

are classified as BMI obese I where respondents do

not have excessive fat. It is precisely muscle size

large enough to increase metabolism to produce

energy. If the energy produced is high, muscle

fatigue will be challenging to occur (Tarwaka,

2015).

This finding is not in line with previous studies'

results, which stated that excess body weight is the

most significant factor in health problems, one of

which is LBP. Excess body weight will put

excessive weight on the spine and put a lot of

pressure on the spine, which can lead to joint

damage (Widjaya & Aswar, 2012; Rochman et al.,

2017).

The results of this study are in accordance with

Amila et all (2015), which showed that there was no

significant relationship between BMI and LBP in

nurses with p-value = 0.294. The analysis of the

Spearman Rank statistical test conducted by Astuti

et all (2015) in their research obtained a p-value =

0.220 so that Ha was rejected. It can be said that

there is no significant relationship between workers'

tenure and complaints of low back pain.

According to Munir (2012), in line with the

increase in BMI, it is directly proportional to a

person's strength in doing work. People with larger

body proportions tend to lift large weights more

easily. If this is done correctly, it is not expected that

excessive muscle stretching will occur, which causes

LBP complaints.

Nurses tend not to pay attention to how their

procedures work in lifting weights. Respondents

who do not experience LBP have maintained an

excellent diet to fit their BMI in the normal

category. In contrast to respondents who experience

LBP, they do not maintain a proper diet, so they are

included in the abnormal category.

According to researchers' assumptions, in order

not to experience LBP, respondents need to maintain

a healthy lifestyle such as maintaining a diet and

exercising regularly so that the fat they have does

not press on the spinal ligaments. Therefore, it is

necessary to increase knowledge about the

consumption of nutritious food under the workload

and calorie needs of each respondent's body every

day.

3.2 The Relationship of Age and Low

Back Pain Complaints

Based on table 2, it is obtained that the p-value =

0.367 (p value> 0.05), meaning that Ha is accepted.

This shows that there is no significant relationship

between age and Low Back Pain in nurses at the

IGD of the RSUD H. Adam Malik Medan. This is

because the majority of nurses are still productive in

their activities. Productive age has strong muscle

strength to lift heavy loads so that the level of LBP

complaints experienced by nurses is still relatively

mild or can still be resolved.

This study's results are in line with research

conducted by Harahap et all (2018), which states

that there is no significant relationship between age

and complaints of LBP with a p-value = 0.593. This

is because the age at risk of LBP complaints and

those who are not at risk of LBP are not far apart,

where respondents at-risk age are 91.7% and age are

not at risk as much as 8.3%.

As a person gets older, bone density decreases so

that it is easy to experience skeletal muscle

complaints and cause pain. Maximum muscle

strength occurs between the ages of 20 - 49 years,

and at the age of 60, the average muscle strength

decreases by 20%. Another factor that causes low

back pain is the non-ergonomic work attitude

(Tarkawa, 2004)

. However, disorders of the spine

do not only occur in the old age group but can also

occur in the younger age group. In a European study,

25% of LBP incidence was found in workers who

had not reached the age of 25 years and 35% at the

age of more than 55 years (Paoli, 1997: Beeck and

Hermans, 2000).

From the results of research conducted on 30

respondents, the most LBP complaints were

experienced by respondents aged > 30 years, as

many as 19 respondents (65.5%). Then, ten

respondents with the age group > 30 years who did

not experience LBP (34.5%), and 1 of them was in

the young age category, that is, <30 years old and

not experiencing LBP. This is following the theory

of Tarwaka (2004), where the first complaint is

usually felt at the age of 35, and the level of these

complaints will increase with age. Good muscle

strength, even though the age is more than 35 years,

is influenced by the nutrition of the food consumed,

adequate resting time, and endurance. Therefore, a

large enough muscle increases the metabolism to

produce energy. If the energy produced is high, it

HIMBEP 2020 - International Conference on Health Informatics, Medical, Biological Engineering, and Pharmaceutical

192

will be difficult for muscle fatigue to occur, thereby

reducing the risk of LBP complaints. When they

have free time while working, nurses should be able

to do simple muscle stretching so that the body

muscles are not stiff due to work.

3.3 The Relationship of Working

Period and Low Back Pain

Complaints

Based on table 3 above, the p-value = 0.611 (p

value> 0.05) is obtained, meaning that Ha is

accepted. This shows that there is no significant

relationship between tenure and Low Back Pain in

nurses at the IGD of the RSUD H. Adam Malik

Medan. The reason why the tenure has no

relationship is because the majority of nurses have a

working period of more than ten years, which means

that they have a lot of experience and are skilled in

nursing. Skilled people tend to make mistakes rarely

so that the possible work risks of experiencing LBP

can be avoided, but this factor contributes to LBP

complaints. Therefore a work rotation system is

needed.

In line with research conducted by Yacob et all

(2018) that there is no relationship between tenure

and LBP complaints, it is evident from the Spearman

rank test, which shows a p-value = 0.403 (> 0.05). In

this study. This can be due to the nurses in the

inpatient room of Bhayangkara Tk II Hospital in

Manado were classified as a new working period

where nurses with a working period of fewer than

five years did not have as much experience as

manual handling in lifting a patient, encouraging

patients, and moving the patient repeatedly, which

eventually bring out the risk of causing complaints

of LBP. On the research conducted by Manengkey

(2016), the results of the Chi-Square test analysis

showed p-value = 0.057 > 0.05, which indicates that

there is no significant relationship between work

tenure and musculoskeletal complaints in emergency

room nurses at Prof. Dr. R. D. Kandou Manado.

According to Islamiati (2014), out of 33

respondents, of the 24 people who had a long

working period, 62.5% experienced LBP

complaints. Among nine people whose work period

was relatively new, 55.6% experienced LBP

complaints. These results indicate that there is no

relationship between tenure and LBP complaints to

forklift operators at PT. Pertamina Lubricants

Production Unit Jakarta.

Based on the observations that have been made,

it is found that 26 respondents who have worked> 10

years 17 of them experienced LBP, and nine other

respondents did not experience it. In comparison,

four respondents who entered the working period

<10 years. Two of them did not experience LBP, and

two other respondents experienced LBP.

Respondents were encouraged to perform work

rotations to reduce the level of risk of experiencing

LBP complaints because the ER is an installation

with the highest workload that demands intense time

and energy.

3.4 The Relationship of Workloads and

Low Back Pain Complaints

Based on table 4 above, it is known that the p-value

= 0.001 (p-value < 0.05), meaning that Ho is

rejected. This shows that there is a significant

relationship between workload and Low Back Pain

in nurses at the IGD of the RSUD H. Adam Malik

Medan. The reason why workload is related to LBP

complaints is because the majority of respondents

have a high workload. Nurses' high workload is

caused by the work capacity that is not in

accordance with the body's ability to handle the

workload.

Nurses' knowledge and skills cannot compensate

for the difficulty of working in the hospital, which

becomes the workload. Nurses are not prepared to

deal with patients with various characteristics, and

nurses are required to make strict observations of

patients during working hours. The nurse stood and

walked for a long time and mobilized more than five

adult patients with various body weights during one

shift. The workload that is borne by nurses every

day increases the risk of experiencing LBP

complaints.

This is in line with the research results of

Indriasari et al (2017), which states that the

workload of each nurse plays a significant role in

increasing LBP complaints. The chi-square test

results showed a significant value of p = 0.003,

which means that there is a relationship between

workload and LBP complaints in nurses in the

operation room of the Yogyakarta City Hospital.

One of the risk factors that cause LBP is job risk

factors such as frequent bending and stooping,

lifting heavy loads (> 11.3 kg), pushing and pulling

(load> 22.5 kg), etc.

According to Risdianti (2018), the greater the

worker's workload weight, the heavier the pain

complaints experienced by the respondent. The

results of research conducted on female porters in

the market Surakarta showed that 53.13% of

respondents who experienced moderate workload

complained of moderate pain, and 56.25% of

Complaints of Nurses’ Low Back Pain Assessed from Individual Characteristics and Workloads

193

respondents with heavy workloads complained of

severe pain (with p-value = 0.000), which means

that there is a significant relationship between

workload and LBP complaints.

Based on the observations of researchers, nurses

often mobilize or assist in the process of transferring

adult patients who have heavy body weights, even

more than five patients per day. This increases the

risk of LBP complaints for nurses. Therefore

respondents are expected to adjust the workload to

their respective body abilities and not push

themselves to work and, as much as possible use

tools to ease the respondent's workload.

4 CONCLUSIONS

There is no relationship between BMI and LBP

complaints among emergency room nurses at the

RSUD H. Adam Malik Medan with p-value = 0,372.

There is no relationship between age and complaints

from LBP among emergency room nurses at the

RSUD H. Adam Malik Medan with p-value = 0,367.

There is no relationship between working period and

LBP complaints among emergency room nurses at

the RSUP H. Adam Malik Medan with p-value =

0,611. However, there is a relationship between

workloads and LBP complaints among emergency

room nurses at the RSUD H. Adam Malik Medan.

It is recommended that nurses use the free time

when working to stretch the muscles so that the

muscles are not stiff due to work, and adjust the

body's ability to the workload being done. The

results of this study can also be used as a reference

in the hospital in the formulation of fixed procedures

(SOP) regarding the work attitudes of nurses when

carrying out nursing actions and the need to pay

attention to their workload, so they are not

excessive, especially by providing assistance for

lifting heavy loads such as moving patients.

ACKNOWLEDGMENTS

We would like to thank the Universitas Prima

Indonesia for its support

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