評估中部某醫學中心護理人員肌肉骨骼不適及 介入成效之研究

Assessment of Musculoskeletal Disorders in Nurses and the Effects of an Intervention Program in a Medical Center in Central Taiwan

袁素娟(Su-Chuan Yuan)

指導教授 ： 周明智

中山醫學大學/醫學院/醫學研究所/博士(2011年)

https://doi.org/10.6834/CSMU.2011.00125

摘要

背景：在許多方面，護理專業不同於其他領域的工作，護理人員身體的工作負荷，尤其是搬運與抬起病人時，經常需要和病人有直接的接觸．且病人及家屬需要醫學的及情緒的支持與幫助。還有，護理工作會引發高的心理壓力，如護理人員常需面對上司、同事和病人間的衝突，另外，在護理工作時，常會遇到人的疾病和死亡而產生的壓力，以及工作角色的不明確、人力不足和輪班造成人體生理日夜節律不協調，以上種種，使護理工作成為肌肉骨骼不適(Musculoskeletal disorder；MSDs)之高風險的職業。
研究目的：第一部分：在瞭解護理人員MSDs之盛行率及其影響因素，作為本研究初探。第二部分：利用OWAS(Ovako Working Posture Analysis System)作業姿勢分析系統，分析護理人員可能危害之作業種類與頻率並與理學檢查結果進行相關分析。第三部分：評估護理人員健康有關體適能經運動介入之成效。
研究方法及資料：第一部分：主要對象為某醫學中心各護理單位之護理人員，經本人同意後，以結構式問卷及理學檢查為研究工具，資料收集自2006年6月至同年12月，有MSDs者共236人，全程參與者198人。第二部分：198位護理人員依其護理作業特性分成六大類護理單位，並依每單位人數多寡，約每10人抽取2至3位典型作業護理人員，拍攝作業情況各3至6時，以進行OWAS分析，共拍攝20人。分析前先將護理人員作業內容依作業動作類型分10類，每15秒擷取一次影像，接著將理學檢查結果與OWAS分析結果做相關分析。第三部份：同為第一、二部分之研究場所，針對護理人員公開徵求，共5個護理單位參與，每單位自願參加運動介入者屬實驗組，剩餘護理人員以隨機抽取與實驗組等量的人員為對照組，實驗組以踏步機運動做介入，為期三個月，研究對象全程參加者共實驗組45人，對照組41人。介入前以問卷調查兩組參與者之運動習慣與工作環境，並於介入前後兩組均量測體適能。以上三部分資料，均以SPSS for window 14.0進行統計分析。
研究結果：第一部分：本研究場所護理人員MSDs之盛行率為65.0%，這高的MSDs症狀以肩膀佔最多67.2%；其次為頸部61.6%；下背佔第三位42.9%。經邏輯斯迴歸分析，發現「工作負荷量」會影響肩膀及腕/手之不適，「有壓力」的勝算比是「適度的」2.364倍及3.463倍；「運動習慣」會影響腕/手之不適，「無運動」的勝算比只有「有運動」的0.240倍；「做伸展操」會影響上背之不適，「無做的」勝算比是「有做的」0.415倍；而「工作單位」會影響頸部之不適，「病房單位」的勝算比是「加護及手術單位」的1.889倍，且均達顯著差異(p<0.05)。第二部分：10大作業分類中，除「行政坐姿作業」為坐姿外，其餘皆為站姿或蹲姿，且所占作業比例相當高（77~91％）。在姿勢危險等級方面，除「徒手搬運醫療器材」及「行政坐姿作業」外，其餘8大作業皆有達到3-4級的危險，其中又以成人加護單位、呼吸照護中心及手術室佔較多。第三部份：介入前，對照組之握力、柔軟度及腹肌耐力均較實驗組好，且達顯著差異(p﹤.05)。介入後，兩組比較，只有心肺耐力有顯著差異(p﹤.05)，且實驗組較對照組好。介入影響方面，經調整介入前，實驗組之體適能在身體質量指數(BMI)、握力、柔軟度、腹肌耐力、背肌耐力及心肺耐力等六項均達統計上差異(p﹤.05)，且實驗組較對照組效果好。
研究結論與建議：第一部分：本研究機構之護理人員MSDs之盛行率高，影響因素為工作負荷量、運動習慣、有無做伸展操及工作單位。第二部分：OWAS 分析結果發現護理人員的作業姿勢很容易達到3~4危險等級的動作，而這些不同作業姿勢、作業型態的頻率也與MSDs的盛行率有顯著相關。第三部份：研究顯示踏步機運動介入對護理人員的體適能有改善。建議：護理工作單位之適時、適度輪調，醫院設備採購及設置時注重人因工程設施、增加輔助工具，主管建立職場壓力管理方案並積極推動社團或健康促進，可減少MSDs的盛行率並提高工作效率。

關鍵字

護理人員 ； 肌肉骨骼不適 ； 理學檢查 ； 作業姿勢分析系統 ； 健康有關體適能 ； 健康促進

並列摘要

Abstract
Background：Nurses require more physical workload when compared with other health professionals, especially during handling and lifting patients to provide close contact for medical and emotional support. In addition, facing conflicting demands between their supervisors and patients raises highly mental stress among nurses. Other stressful factors may include job role ambiguity, staff shortage, duty shift and the close contact with human who are severely suffering, critically ill, and may be dying. All the above reasons make nursing profession a highly risk occupation and can subsequently lead to physical or musculoskeletal disorders (MSDs).
Objective：There are three objectives. Firstly, to identify the prevalence of MSDs and related factors in nurses. Secondly, to analyze the types and frequency distribution of risk factor within nursing tasks by Ovako Working Posture Analysis System (OWAS) with the correlation of physical examinations. Thirdly, to assess how exercise intervention might affect nurses’ physical fitness.
Methods and Materials：Part I: To assess the prevalence of MSDs, a structured questionnaire and physical examination were used simultaneously in this study. From June to December 2006, a total of 363 nurses who worked in a medical center in central Taiwan registered in this study. After receiving physical examination by specialists, there were 236 nurses identified with MSDs, and 198 of them had completed the whole study program. Part II: For OWAS analyzing, we first divided nursing care units into six categories according to their task characteristics. From each category, we then randomly selected 20% nurses, who carried out typical nursing duties. A total of 20 representative nurses were chosen and, a three-to-six-hour video was taken for each of them to record their body postures during work. Collective working postures were then classified into 10 categories, and images for every 15 seconds were then picked from each category for further analyzing by OWAS system. Correlations between the result of OWAS and physical examination of the representative nurses were explored. Part III: For exercise intervention program, voluntary participants were recruited from five ward units in the same medical center. A total of 45 nurses were assigned to the experimental group, and they engaged on a treadmill exercise every day for three months as their intervention program. Another 41 nurses from these participating units were assigned as control subjects, and they did not use treadmill during the period of time. Questionnaires on exercise habits and work environment were administered to every participant prior to the exercise program. The health- related physical fitness of nurses was tested before and after the intervention program.
Results：Part I: Our results showed that the prevalence of MSDs was 65% among nurses working at the medical center in central Taiwan. The most common MSDs symptoms appeared in shoulders in 133 nurses (67.2%), followed by that appeared in neck in 122 nurses (61.6%), and in low back in 85 nurses (42.9%). Logistic regression analysis revealed that significant factors such as workload, and/or emotional stress were associated with MSDs. The degree of nurses’ workload correlated positively to the level of discomfort appeared in shoulder and hand/wrist. The odds of a nurse feeling heavy and moderate workload, who experienced discomfort in shoulder and hand/wrist was 2.364 and 3.463 respectively (p<0.05). The odds ratio of nurses who exercised regularly and experienced discomfort in shoulder and hand/wrist was only 0.24 compared to those who did not have exercise habit (p<0.05). Stretching exercise alleviate discomfort of the upper back. The odds ratio of nurses without stretching and feeling upper back discomfort, compared to those keeping stretching exercises while feeling upper back syndrome, was 0.415(p<0.05). In addition, specific working area was associated with shoulder and neck discomfort. Nurses working at ward units are more likely to experienced shoulder and neck syndrome than those working at intensive care unit or operation room, with an odds ratio of 1.889 (p<0.05). Part II: Among the ten working posture categories, the most common ones were standing and squatting (75.53~91.30％). The remaining eight working postures were reported with hazardous levels 3 to 4, and these highly hazardous postures were found frequently in nurses working in adult ICU, respiratory care unit and operation room. Further analyses found significant elbow discomforts in nurses who provided whole body nursing care to those patients resided in beds. Similar correlations was also found closely related in nurses who provided standing supportive medical care, and demonstrated hand/wrist, and lower extremity discomforts. While the nurses performing patient movement tasks had experienced neck/upper back, and lower extremity discomfort, those who doing sitting office task had most often encountered shoulder discomfort. Nevertheless, nurses executing standing office tasks had experienced more wrist discomfort. Part III: Before exercise intervention program, the control group had significantly better grasp strength, flexibility and durability of abdominal muscles than the experimental group (p<0.05). After intervention, the experimental group performed better on body mass index (OR=3.90), grasp strength (OR=1.36), flexibility (OR=2.14), durability of abdominal and spinal muscles (OR=1.68), back muscle durability (OR=1.15), and cardio-pulmonary function (OR=1.64) with significant difference in all of the above six indicators of fitness (p<0.05).
Conclusion and Suggestion：Our results demonstrated that the prevalence of MSDs in nurses is as high as 65% and the most related factors included their workloads, exercise habits, and whether they kept stretching exercise and in which working area they attended. In addition, the results of OWAS analysis revealed that the working postures used by nurses often reached hazardous level 3 to 4. The significant correlations were confirmed between the MSDs prevalence and working posture, and also between the prevalence and the categories of nursing tasks. Furthermore, we proved that the treadmill exercise program was beneficial for nurses and improved their physical fitness dramatically. In conclusion, we strongly suggest that ergonomic issues of nurses should be considered and hospital units should provide instruments which can be easily accessed by nurses. It is also important to reduce nurses’ MSDs symptoms by decreasing their workload, improving their working environment, and monitoring the shift rotation to the most optimal status for nurses. Managers in the hospitals should provide stress management program and health promotional activities to help nurses, particularly in doing stretching exercise and maintaining regular exercise habit. OWAS analysis system should also apply to improve the nurses’ working posture and we strongly believe the later can significantly reduce the prevalence of MSDs in nurses. At last, we strongly recommend that nurses should keep regular exercise habit in order to ameliorate their physical fitness and to improve the efficiency of their professional nursing care.

並列關鍵字

nurse ； musculoskeletal disorders (MSDs) ； physical examination ； Ovako Working Posture Analysis System (OWAS) ； health-related physical fitness ； health promotion

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