RECENTLY GRADUATING PRACTICAL NURSES’ SELF- PERCEIVED PHYSICAL WORK ABILITY AND PERCEIVED
PHYSICAL DEMANDS IN NURSING
Eveliina Kauppinen Master‘s thesis
Degree Programme in Health Sciences
University of Eastern Finland Department of Health and Social Management
August 2018
ITÄ-SUOMEN YLIOPISTO, Yhteiskuntatieteiden ja kauppatieteiden tiedekunta, sosiaali- ja terveysjohtamisen laitos, terveystieteiden maisteri.
KAUPPINEN, EVELIINA: Vastavalmistuvien lähihoitajien itsearvioitu fyysinen työkyky ja lähihoitajien arvio ammatin fyysisestä kuormittavuudesta
Pro gradu-tutkielma, 82 sivua, 5 liitettä (21 sivua)
Tutkielman ohjaajat: FT, Professori Johanna Lammintakanen
TtT, Yliopistonlehtori Susanna Järvelin- Pasanen TtM, YTM, Projektitutkija Anna Karttunen
Elokuu 2018____________________________________________________________
Avainsanat: lähihoitaja, fyysinen kuormitus, fyysinen työkyky, lähihoitaja opiskelija Tämän pro gradu -tutkielman tarkoituksena oli selvittää vastavalmistuvien lähihoitajien arviota sekä fyysisestä työkyvystään, että myös lähihoitajan ammatin fyysisestä kuormittavuudesta. Tutkimuksen tavoitteena oli tuottaa tietoa, jonka avulla voidaan tulevaisuudessa edistää lähihoitajaopiskelijoiden fyysistä työkykyä ja hyvinvointia työelämässä, mutta myös koulutuksen aikana.
Tutkimuksen aineisto kerättiin toukokuussa 2018 sähköisellä kyselylomakkeella, joka oli laadittu tätä tutkimusta varten. Suomen perus- ja lähihoitajaliitto lähetti sähköpostitse tutkimustiedotteen kaikille huhti-kesäkuussa valmistuville lähihoitajille, jotka olivat liiton opiskelijajäseniä. Tutkimuksesta tiedotettiin myös liiton Facebook- ja nettisivuilla. Kyselyn aineisto analysoitiin SPSS- tilasto-ohjelmalla ja tilastollisina menetelminä käytettiin jakaumien (frekvenssijakauma, prosenttijakauma, keskiarvo, keskihajonta) koontia sekä muuttujien välistä tilastollista merkitsevyyttä testattiin khiin neliö- testillä. Lisäksi avoimet vastaukset analysoitiin sisällönanalyysillä. Noin 2600 vastavalmistunutta lähihoitajaa sai tutkimustiedotteen, mutta täysin tarkkaa vastausprosenttia on mahdotonta arvioida virheellisten sähköpostiosoitteiden takia.
Kyselyyn vastasi yhteensä 231 lähihoitajaa.
Tutkimukseen osallistuneet lähihoitajat arvioivat terveydentilansa keskimäärin hyväksi.
Tutkimus vahvisti aiempaa tietoa siitä, että tuki- ja liikuntaelimistön ongelmat ja ylipaino ovat ammattiryhmän keskuudessa yleisiä sekä lähihoitajat ovat liikunnallisesti melko inaktiivisia. Lisäksi, valmistuneet lähihoitajat arvioivat fyysisen työkykynsä keskimäärin huonommaksi kuin sosiaali- ja terveysalan työntekijät Suomessa.
Liikunnallinen inaktiivisuus ja tuki- ja liikuntaelimistön kivut olivat yhteydessä arvioon fyysisestä työkyvystä sekä tuki- ja tukielimistön kivut lisäsivät kokemuksia ammatin fyysisestä raskaudesta. Myöskin korkeaksi koettu ammatin fyysinen työrasitus ja huono fyysinen työkyky lisäsivät lähihoitajien ajatuksia vaihtaa ammattia, vaikka lähes kaikki lähihoitajat ilmoittivat jatkavansa ammattialalla. Ammatin fyysiset vaatimukset olivat toiseksi yleisin syy ajatuksiin vaihtaa ammattia psyykkisten vaatimusten jälkeen.
Tulokset osoittivat, että vastavalmistuvien lähihoitajien fyysisen työkyky ei vastaa ammatin fyysisiä vaatimuksia. Koska jo vastavalmistuneilla lähihoitajilla on fyysisen työkyvyn kanssa ongelmia, tulevaisuudessa on tarpeen tukea lähihoitajien fyysistä työkykyä entistä enemmän ja arvioida heidän työkykynsä ennen koulutuksen aloittamista, koulutuksen aikana, mutta myös työelämässä. Tulevaisuudessa tarvitaan
UNIVERSITY OF EASTERN FINLAND, Faculty of Social Sciences and Business Studies, Department of Health and Social Management, Master of Health Sciences KAUPPINEN, EVELIINA: Recently graduating practical nurses‘ self-perceived physical work ability and perceived physical demands in nursing
Master's thesis, 82 pages, 5 appendices (21 pages)
Thesis supervisors: PhD, Professor Johanna Lammintakanen
PhD, Senior Lecturer Susanna Järvelin- Pasanen
MSc. (Health & Soc. Sci.) Project Researcher Anna Karttunen August 2018___________________________________________________________
Keywords: practical nurse, physical load, physical work ability, student nurse
The purpose of this study was to describe newly graduating practical nurses‘ self- perceived physical work ability and how physically demanding they considered the profession. The aim of the study was to produce knowledge about study populations‘
physical work ability that, in the future, newly graduating nurses‘ physical work ability and well-being could be promoted in the work life but also during the education.
A single set of electronic self-assessment questionnaires were administrated in cooperation with Finnish Union of Practical Nurses in May 2018. The research request was sent to all practical nurses that graduated from the education during the April-June and were student members of the Union. The research was also promoted in the Union‘s website and on their Facebook. In this study, the data were analyzed by SPSS and the data was described as percentages, frequencies, averages and standard deviations.
Furthermore, the statistical significances between variables were analyzed with the chi- square test. Moreover, the open-ended responses were analysed with content analysis.
Around 2600 graduating practical nurses were invited to take part in the research but as hundreds of emails got rebounded, it is impossible to state the exact response rate for the study. The study population consisted of 231 nurses.
The practical nurses perceived their current state of health status on average as good.
The research confirmed the earlier knowledge that practical nurses have high prevalence of musculoskeletal disorders, overweight and practical nurses are physically relative inactive. Also, the just graduating practical nurses perceived their current state of physical work ability lower than average social and health care workers in Finland.
Being physically active, having no frequent disorders in neck, - and-shoulder and back areas were associated with greater self-rated physical work ability. The perceived physical load in the occupation was rated lower without frequent musculoskeletal disorders. The high physical demands and lower perceived physical work ability were associated to increase practical nurses‘ thoughts to change the occupation although most of the study participants expressed to continue their career in nursing. Physical demands in nursing were the second most usual reason to have thoughts to change the occupation additionally to psychological demands.
The findings showed an imbalance between practical nurses‘ physical work ability and work-related physical demands in nursing. In the future, the nurses physical work ability must be promoted and assessed more before starting education, during education but also in work life. More studies are needed to research nurses‘ physical work ability.
TABLE OF CONTENTS
1 INTRODUCTION ... 1
1.1 A background of the study ... 1
1.2 The purpose and aims ... 4
2 THE CONCEPTS OF WORK ABILITY, WORK-RELATED DEMANDS AND PHYSICAL WORK ABILITY ... 5
2.1 The concept of work ability ... 5
2.2 The stress-strain model ... 8
2.3 Physical work ability and individual characteristics ... 10
2.3.1 Gender ... 11
2.3.2 Age ... 12
2.3.3 Physical fitness ... 13
2.3.4 Health status ... 14
2.4 Methods to assess a person’s physical work ability ... 16
3 THE KNOWLEDGE OF WORK-RELATED DEMANDS IN NURSING ... 19
3.1 The characteristics of practical nurses ... 19
3.2 Knowledge concerning practical nurse’s work-related demands ... 20
3.2.1 Physical demands ... 20
3.2.2 Psychological demands ... 21
3.2.3 Social demands ... 22
3.2.4 Organizational factors ... 23
3.3 Physical load and its assessment in a nursing occupation ... 25
3.4 Summary of the literature review and framework of the study ... 29
4 THE MATERIALS AND METHODS ... 31
4.1 Research methodology and design ... 31
4.2 The questionnaire and its development ... 33
4.3 Study population and data collection ... 36
4.4 Data analysis ... 38
4.4.1 Qualitative analysis ... 43
5 RESULTS ... 45
5.1 The background characteristics of the study population ... 45 5.2 The self-perceived health status and physical fitness of graduating practical
5.4 The graduating practical nurses’ self- perceived physical demands in nursing
... 53
5.5 The graduating practical nurses’ future visions ... 56
5.6 Relationship between variables and perceived physical work ability and physical straining ... 59
5.6.1 Factors related to the perceived physical work ability ... 60
5.6.2 Factors related to the self-rated physical load of the occupation ... 61
5.6.3 The relationship between physical work ability, perceived physical demands and having thoughts to change occupation ... 63
6 DISCUSSION ... 65
6.1 Interpretation of the results ... 65
6.2 Ethical considerations ... 70
6.3 Reliability and validity ... 73
6.4 Suggestions for further researches ... 76
7 CONCLUSIONS AND RECOMMENDATIONS ... 77
7.1 Recommendations for educational level according to study findings ... 78
7.2 Suggestions for workplaces according to study findings ... 81
7.3 Suggestions for graduating or student nurses according to study findings ... 82
REFERENCES ... 83
APPENDICES ... 98
TABLES TABLE 1. The three models of work ability and their brief definitions ... 5
TABLE 2. The used data analysing methods of the study. ... 39
TABLE 3. The old categorizations of the variables and the renewed categorizations used in the chi squared test. ... 41
TABLE 4. The background information of study population ... 46
TABLE 5. The work-related characteristics of study population. ... 47
TABLE 6. The prevalence of the musculoskeletal disorders during the course of the one year. ... 48
TABLE 7. The perceived ability to work in nursing after five years and until retirement age. ... 51
TABLE 8. The perceived level of physical demands in the occupation measured by RPE scale ... 53
TABLE 9. The perceived straining in the musculoskeletal system after work shift during the past month. ... 56 TABLE 10. The plans after graduating from the Vocational education in Social and
TABLE 11. The main reasons of having thoughts to change the profession ... 58 TABLE 12. The relationship between variables and self-rated physical work ability. .. 61 TABLE 13. The relationship between variables and self-rated physical demands in nursing. ... 63 TABLE 14. The relationship between physical work ability and perceived level of physical load and thoughts to change the occupation. ... 64
FIGURES
FIGURE 1. A modified model of work ability house. ... 7 FIGURE 2. A modified version of the stress-strain model to address the relationship between the stress factors, individual characteristics and experienced strain ... 9 FIGURE 3. The summary of the work-related demands in nursing. ... 30 FIGURE 4. The process of developing the questionnaire from the research problems to the actual data collection. ... 34 FIGURE 5. The researcher‘s own suggestions to assess applicant‘s health and physical capabilities in entrance exam. ... 79
APPENDICES
APPENDIX 1. The typical workplaces and work characteristics of practical nurses .... 98 APPENDIX 2. The content of the questionnaire. ... 100 APPENDIX 3. The cover letter of the questionnaire. ... 102 APPENDIX 4. The used questionnaire in the study. ... 104 APPENDIX 5. Example of qualitative analysis. phase reduced citation and their
categorisation. ... 119
ABBREVIATIONS
ATH National Study of the Adult Finnish Population BMI Body mass index
EC European Commission
EDUFI Finnish National Agency for Education
EU-OSHA European Agency for Safety and Health at Work FIOH Finnish Institute of Occupational Health
MSAH The Ministry of Social Affairs and Health MSDs Musculoskeletal disorders
RPE Rated Perceived Exertion
SuPer The Finnish Union of Practical Nurses SPSS Statistical Package for the Social Sciences TENK Finnish National Board on Research Integrity THL National Institute for Welfare and Health VO2max Maximal oxygen uptake
WAI Work Ability Index
1 INTRODUCTION
1.1 A background of the study
The nursing has been acknowledged as a very physically demanding profession (Trinkoff et al. 2003). Therefore, nurses must maintain a good overall physical fitness to work in the occupation (Tamminen-Peter et al. 2007, 24). In the future, the increasing physical demand in the social and health care sector is a major challenge in nursing (Mishra 2015, 414). Currently, the steep increase of elderly people cause that population require a greater amount of help, treatment, care and support. That is due to occurrence that several diseases among aging people, for instance, memory disorders, functional impairments and various chronic conditions have acknowledged increasing the needed care and populations‘ use of social and health care services. (EC 2012, 3-4; Mishra 2015, 414 Laine et al. 2003, 146; MSAH 2017, 13-15) The ever-increasing demands have been already reported among the social and health care workers: altogether, 71 % of Finnish practical nurses have experienced the workload heavy, which has been arisen with 22 % during the past four years (Erkkilä et al. 2016, 11, 22). The physical demands have especially increased in the ward sections of healthcare centres and in the elderly care (Laine et al. 2011, 30).
Furthermore, the workforce loss is currently a critical challenge in the social and health care sector. The workforce loss has previously estimated as most crucial during the years 2016–2020 when the ―baby boomers‖ generation (born in 1940–1950) will be retiring. Therefore, the social and health care sector must increasingly recruit a new workforce to replace those who are retiring. However, the sector has had difficulties to retain and recruit professional workers. (EC 2012, 1, 4-5) Having a lack of professional social and health care workers to replace those who have retired, means that the demands have increased and will increase among those nurses who stay in the occupation (Baumann et al. 2001).
According to the earlier discussed changes and challenges, the wellbeing and work ability of social and health care workers should be actively promoted that the employees could have enough resources and capabilities to cope with the increasing demands and high workload (Laine et al. 2003, 146). Like the Finnish Union of Practical Nurses (Super) have pointed out, the practical nurses‘ occupation has become more demanding,
and ttherefore, it is essential that newly graduating nurses maintain a good work ability (Nevala & Simberg 2016, 46-47). Maintaining a regular physical exercise program and having good physical fitness has indicated to be an important factor to maintain the person‘s work ability and thus, to improve the capability to cope with the work-related physical demands (Suominen 1997, 17; Nuikka 2002).
Nevertheless, the threat for population‘s physical work ability is the increasing sedentary lifestyle, increased prevalence of obesity and decreased physical condition among working age population (Husu et al. 2011, 10, 13, 37). Almost half of the Finnish population aged 20-54 has acknowledged not meeting the recommendations of weekly physical activities and almost 24 % of that population has reported not do any kinds of leisure time physical activity. Also, 17 % of working age women and 22 % of working age men have acknowledged as obese (BMI ≥ 30 kg/m2). (Murto et al. 2017) The work ability and well-being of the employees are the most valuable resource to secure the well-functioning and high-quality social and health care services for the population who need them (Hänninen et al. 2005, 15; Laine 2014, 15; Laine et al. 2006, 6). The consequences of excessive workload in the social and health-care sector have well identified; it decreases the patient safety (Lang et al. 2004), is a threat for nurse‘s health, (Elfering et al. 2002) lowers the nurses‘ work satisfaction and may cause high nursing turnover and nursing shortages (Duffield & O'Brien-Pallas 2003; Estryn- Behar et al. 2013, 98). For instance, nurse‘s poor or fair physical health, low work ability and physical exhaustion have associated with the thoughts and intentions to change the occupation (Estryn-Behar et al. 2003, 98; Camerino et al. 2013, 190). Over 70 % of Finnish practical nurses have expressed to have intentions to leave the occupation meanwhile when the work enjoyment work has decreased. That may be a natural occurrence due to increased work-related demands during the years (Erkkilä et al. 2016, 12, 23). Losing the professional workforce from the social and health-care sector is a huge concern according to the well-working services (Erkkilä et al. 2012, 50) and especially during the time when the population would need care and treatment increasingly.
This Master‘s thesis was promoted by the lack of sufficient knowledge about newly graduating practical nurses‘ physical work ability and its increasing need to support
more actively the work ability of social and health care staff according to the earlier discussed future circumstances and changes. Based on the earlier conducted studies, health care workers and nurses have indicated to have a high prevalence of overweight, musculoskeletal disorders (MSDs) but also low or reduced physical capacity (Pohjonen 2001a; Fronteira & Ferrinho 2011; Torgén et al. 1995). Over the years, the prevalence of MSDs among nurse students have studied internationally (e.g. Smith et al. 2004;
Smith et al. 2003; Smith et al. 2005; Abdelu & Offei 2015) and there have established studies which have concentrated to examine the physically active lifestyle among nursing students (e.g. Da Silva et al. 2013; FitzGerald 2015; Hawker 2012). According to the findings of earlier studies, it has been found that nursing students have a high prevalence of MSDs and they have a high risk for developing MSDs. Also, nursing students have been reported to have low physical activity level. Still, this current study is the first one to examine the physical work ability and perceived physical demands among graduating practical nurses in Finland.
The practical nurses are the largest occupational group who operate in the social and health-care sector in Finland and they have a significant role to promote all aged people and customers‘ health, well-being, and development (Nevala & Simberg 2016, 5). In an international context, the term ‗practical nurse‘ refers a nurse, who maintains lower level nursing skills and a shorter period of specialized nursing education than a registered nurse (RN=a University of Applied Sciences). The use of term ‗practical nurse‘ varies around the world: for instance, in Australia, the practical nurse is labelled as an enrolled nurse, in the United States as licensed practical nurse or depended on the territory, as licensed vocational nurse. (Simoens et al. 2005, 16) In this master‘s thesis, we mainly use the term ―practical nurse‖ to define the study population since the term is used widely by the Finnish National Agency for Education. In this study, we state the study population as graduating practical nurses who have just graduated or were just graduating from the education during the April-June 2018 as the empirical data was collected in May 2018.
1.2 The purpose and aims
The purpose of this study was to describe newly graduating practical nurses‘ perceived physical work ability and how physically demanding they consider the profession. The aim of the study was to produce knowledge about study populations‘ physical work ability at the educational level, social and health care organizations- and associations but also to workplaces. This study provides a view and discussion for the development practices on how in the future, the newly graduating nurses‘ physical work ability and well-being could be promoted in the work life but also during the education. The study is a good starting point for the further research in the field.
The specific research questions of the current study were as follows:
1 Based on the self-perceived assessment, what kind of health status and physical fitness graduating practical nurses assess to have?
2 How practical nurses evaluate their physical work ability, and how physically demanding they consider the profession?
3 Which background variables (e.g. gender, age, physical activity level) are associated to have an impact on the perceived physical work ability and experienced physical demands in nursing?
4 What kind of future visions graduating nurses have, for instance, according to staying in the occupation/social and health-care sector?
2 THE CONCEPTS OF WORK ABILITY, WORK-RELATED DEMANDS AND PHYSICAL WORK ABILITY
This Master‘s thesis theoretical framework is divided into two main sections. First, we declare the theoretical background of the work ability and stress-strain model and furthermore, we discuss the concept of physical work ability and about those individual characteristics which may have an impact on perceived work ability. Also, we discuss the possible methods to assess a person‘s physical work ability.
2.1 The concept of work ability
The concept ‗work ability‘ can be specified differently depending on the context of its‘
use; the concept may get varying definitions among employee and employer and between the legislation and research community. Also, the concept of work ability and its dimensions have altered as new models of work ability have established over the years. (Ilmarinen et al. 2006, 19-20) Mäkitalo and Palonen (1994, 155-158) have classified the work ability and its related factors into the three different models with differing definitions and viewpoints. The presented three models of work ability are medical, balanced and integrated models (Table 1).
TABLE 1. The three models of work ability and their brief definitions (Mäkitalo &
Palonen 1994, 155-162; Mäkitalo 2010, 163).
Medical model
―Health‖ Balanced model
―Functional capacity in relation to work requirements‖
Integrated model
―System‖
Starting point individual‘s psychophysical system assessed in clinical settings
individual‘s characteristics in relation to work requirements
compromises individual, community and operational environment Key term disorder /health functional ability action Assessment of
work ability
diagnoses work ability tests, assessment of work requirements
systematic/
developing analysis of disruptions Promotion of work
ability
treatment of diseases
(“healing”) promotion of functional capacity or decreasing the work requirements (“adaptation”)
tests and
experiments which develop the operations (” developing”)
Although multiple models and definitions for the work ability have established over the years, this study examined the work ability from the balanced viewpoint. The balanced model emphasizes the relationship between an individual‘s functional capacity (physical and psychological, social), education, skills, work experience but also the work-related motivation and their balance according to the actual work-related demands and exposure to stress factors. (Mäkitalo & Palonen 1994, 155-163; Mäkitalo 2010, 163) Based on the balanced model, the person has abilities to work if he/she can perform the work without excessive overload and thus, the demands are in balance with the individual‘s characteristics (Ilmarinen et al. 2006, 22). Therefore, it is necessary to clarify both the work-related demands and individual‘s capabilities. The balanced model of work ability is based on the stress-strain model (Rutenfranz 1981) which is presented more precisely in the following section, 2.2.
In this study, we especially highlight the importance to promote an individual‘s work ability to have balanced resources to operate in the occupation. Therefore, the nurse must have a certain level of work ability according to the occupational demands.
Furthermore, if the work-related demands are not in balance, the work load should be adjusted to meet the person‘s resources. According to that, we have two contrary viewpoints for the physical work ability: personal resources and surrounding nursing practice environment. Instead, medical and integrated models have not acknowledged as adequate viewpoints for our study; we did not research the work ability from the objective viewpoint with clinical methods (medical model). Also, the integrated model of work ability was not tightly related to our study by bonding the worker‘s work ability to be depended on the time dimension and work community.
The Finnish Institute of Occupational Health (FIOH) has developed a multidimensional work ability model (work ability house), which is based on various types of researches and interventions, mainly established in the 1990s. Based on the work ability house (figure 1), the work ability consists of various dimensions which emphasize that the all dimensions (floors) of the house support other dimensions and if one floor gets overloaded, the causes may in long-term also impact negatively on other floors (Ilmarinen et al. 2006, 22-24).
FIGURE 1. A modified model of work ability house (Ilmarinen 2006, 80-81).
In this research, we are mainly interested about the basement of the work ability house which compromises person‘s functional capacity (physical, social, psychological) and health status (Ilmarinen 2006, 79-80; Ilmarinen et al. 2006, 19-20). Therefore, we aimed to describe the level of graduating practical nurses‘ physical capacity and health status.
The person‘s functional ability and health status have examined as the most important components of work ability; based on the study by Ilmarinen and colleagues (2005), the functional capacity and person‘s health have demonstrated the highest explanation rate (39 %) for employee‘s work ability level.
The following floors of the work ability house are composed of the individual‘s professional competences and values: knowledge and skills, motivation and attitudes to perform the work (Ilmarinen 2006, 79; Ilmarinen et al. 2006, 19-20). In this research, additionally to person‘s health and physical capacities we were interested about the fourth floor of the work ability house which compromises the actual work and work- related factors, for instance, work requirements, work community and management of the organization (Ilmarinen 2006, 81; Ilmarinen et al. 2006, 19-20). Therefore, clarified the perceived physical demands in nursing and physical work ability was assessed as a
demands of the nursing profession and the organizational factors which may impact on work ability and coping with the work-related demands are discussed briefly in the section 2.3.
Furthermore, the outermost part of the model, society forms the macro environment for the employee‘s work ability. Society includes, for instance, surrounding social- and occupational policies and services and infrastructure (Ilmarinen 2006, 81; Ilmarinen et al. 2006, 19-20). The implemented political changes and policies; laws and promotion projects have a high impact on the nursing occupation; for instance, Finnish social and health care reform (sote) demand new working methods from the nursing personnel (Hakala et al. 2011, 12, 26; Nevala & Simberg 2016, 7, Nybondas- Kangas et al. 2017, 52-64; Fronteira & Ferrinho 2011, 15). Hence, as a background for this research is the knowledge that in the future the nursing occupation may become more challenging and the work environment may change from the current situation (see more 1.1).
2.2 The stress-strain model
The external stress factors (load), individual‘s load response and straining can be examined with a stress-strain concept (figure 2), which was originally developed to evaluate the work-related physical demands. According to the stress-strain concept by Rutenfranz (1981), the work-related external stressors have categorized into physical, psychological and social demands. The individual‘s response to the external stress factors is highly dependent on the individual‘s characteristics (e.g. functional capacity, health, age, gender, and occupational experience) and thus, the balanced amount of the workload varies between the persons. The experienced strain can be indicated by self- perceived symptoms and feelings or changes in the employee‘s work performance.
(Rutenfranz 1981) In the optimal situation, the work-related demands promote the individuals‘ well-being and work ability by increasing the work-related enjoyment, giving resources and motivating the employee. But in contrast, the unbalanced stress factors may also cause negative symptoms by causing overload or underload.
(Kämäräinen et al. 2009, 102-104; Lindström et al. 2002, 9)
FIGURE 2. A modified version of the stress-strain model to address the relationship between the stress factors, individual characteristics and experienced strain (modified Rutenfranz 1981).
Overloading may occur if the work is continuously heavy, difficult, or the amount of work is excessive (Hanhinen et al. 1994, 28). Therefore, work-related demands cause changes in the individual‘s physiological and psychological condition resulting in negative feelings-, decreased functional capacity and/or increases risk for the diseases and work-related injuries (Lindström et al. 2002, 11; Hanhinen et al. 1994, 28). The overload may lead to changes in the heart rate by accelerating the breathing rhythm, result in changes in the blood pressure and hormonal responses and the person may perceive symptoms of fatigue and sweating during the actual work performance or after a couple of hours of the work shift (Rauramo 2008, 96; Zwart et al. 1996, 2). A fair‘s workday in the aspect of intensity and duration is a work shift which enables an employee to recover physically and psychologically before the following work shift or workday (Lindström et al. 2002, 3; Hanhinen et al. 1994, 36). For instance, it is recommended that work-related physical demands should be around 30-40% of person‘s VO2 max during the work shift to avoid overloading (Åstrand et al. 2003, 505). Instead, underload means the situation when there is too less work, it is passive or too easy according to the individual‘s capabilities (Hanhinen et al. 1994, 28).
The characteristics which may impact on individual‘s coping with the work-related stress factors are, for instance, the person‘s age, motivation, work ability, functional capacity, health status, gender, and professionalism or experience to perform the certain
work tasks (Takala 2007, 48–49; Lindström et al. 2002, 3; Rutenfranz 1981, Hanhinen et al. 1994, 30). The balance between the individual and work-related demands needs regular assessment; the resources of the individual alter during the life (e.g. ageing, working after long-term diseases) and the work requirements and demands fluctuate as the society develops and reconstructs (Ilmarinen 2006, 8; Hanhinen et al. 1994, 28).
The importance of assessing the work-related demands and their impact on individual‘s health and work ability is also noticed in the Finnish legislation. According to the Occupational Safety and Health Act (738/2002 25 §), if the employee is exposed to stress factors that may be a risk for his/her health, the employer must start on action to avoid or reduce the risk of overload. Thus, the Act indicates that the employer is obliged to declare and assess the work-related demands and employee‘s straining that may be dangerous or risky for an individual‘s well-being.
In this study, we use as a framework the discussed stress-strain concept (Rutenfranz 1981). According to the model (figure 2) and objectives (1.2) of the current study, the practical nurses‘ occupation includes a variety of external stress factors (in this study:
physical demands) and the nurse‘s response to those stressors is mainly dependent on the individual‘s characteristics (e.g. age, gender, functional capacity). Therefore, we aimed to explore how those individual characteristics may be associated with the experienced physical demands in nursing (research question 2). Although stress-strain model indicates various personal characteristics, in this study we are interested to explore the relationship between a person‘s self-rated physical work ability, physical fitness level, the prevalence of MSDs, person‘s gender, age and the perceived physical demands.
2.3 Physical work ability and individual characteristics
A person‘s physical work ability can be defined to consist of the same factors as physical capacity; depended on the occupation, a worker must maintain a certain level of physical capacity to cope with the work-related demands (Sainio et al. 2006, 136;
Suni 2001, 75). Therefore, a person‘s physical work ability compromises the individual‘s capacity or well-being of the respiratory-, circulatory and musculoskeletal systems (Takala & Viikari-Juntura 1995, 108-109; Korhonen et al. 1995, 101-105) and a balance between an employee‘s resources, work-related requirements and external
factors of the work (Koskinen et al. 2006a, 111). This means that the physical work ability of nursing personnel must be evaluated according to the work-related physical demands: the work characteristics may differ according to the social and health care sectors (tasks) and specialisations (Appendix 1).
For the next, we take a closer look for the characteristics which may impact on person‘s physical work ability and the capabilities and resources to cope with the work-related physical demands. The main aim is to emphasize the features which are beneficial for this research. Furthermore, we also discuss the possible methods to assess the employee‘s physical work ability.
2.3.1 Gender
A nurses‘ gender may have an impact on the capability to cope with the physical demands, mainly due to differences in the physical capacity between genders. Physical capacity can be defined as a person‘s functional capacity to perform or accomplish a certain physically demanding task (Genaidy 1996, 219). Moreover, physical functional capacity can be divided into three segments: person‘s overall performance level (anaerobic and aerobic), muscle condition (power, endurance and elasticity) and motoric skills (coordination, reaction skills, balance and kinaesthetic resolution) (Louhevaara &
Lusa 1992).
Male persons have acknowledged having higher cardiorespiratory and musculoskeletal capacities (Suni et al. 2012 125-175; Nygård et al. 1991). Furthermore, male nurses have acknowledged having higher self-rated work ability compared to female nurses (Camerino et al. 2003, 90). The gender differences in physical capacity are mainly due to the level of physical strength; female remain normally less muscular strength and mass than their counterparts (Takala 2007, 48-49; Vella 2008, 11). The differences in muscular strength and mass are dependent on the exact muscle group: the most significant differences are in the strength of the upper extremities as women maintain on average 45-55 % of men‘s upper extremity strength. (McArdle et al. 2010, 496;
Bohannon 1997; Frontera et al. 1991) Therefore, the activities that require using of strength, speed or power, the woman‘s smaller muscle mass compared to the male in relation to the total body weight may result in differences in the performance potential.
woman‘s smaller heart size and total haemoglobin (haemoglobin concentration x blood volume) may be a major factor limiting the performance. (Wells 1985, 89) In nursing occupation, nurses need especially use muscular strength in patient transfers, but also nurses need cardiorespiratory endurance; work includes a lot of walking and working in an upright position (see more 3.2.1)
The gender differences in the muscle strength may cause an occurrence that female must work closer to their maximum capacity when performing physically demanding work tasks compared to their counterparts (Lewis & Mathiassen 2013, 27). According to some assumptions, the females‘ physical work capacity is recognized on average to be two-thirds of the male‘s physical work capacity (Genaidy 1996, 221). Still, it must be noticed that the level of gender differences varies between individuals and in some occasion, gender differences may be minor. The differences in physical performance among genders can be diminished with the regular physical exercising although the differences of physical capacity between the genders are quite stable during the person‘s life (Shephard & Bonneau 2002, Kraemer et al. 2001).
2.3.2 Age
The age of the nurse may usually have an impact on a person‘s work ability and capability to work in the physically strenuous occupation. That is caused by the phenomenon that the individual‘s physical capacity normally decreases linearly with the advancing age. The aging impacts mostly on a person‘s physical capacity by causing changes in the individual‘s muscular strength, respiratory-, and cardiovascular systems.
(Ilmarinen 2006, 41, 118; Hänninen et al. 2005, 44) According to a study among home care workers, the study population‘s ability to cope with the physical work demands was found to get lower as year as 35 years age (Pohjonen 2001b).
The capacity and well-being of the respiratory and cardiovascular system are one of the most important factors in the physically demanding occupations and they have an impact on coping with the work-related demands (Shephard & Bonneau 2002). The cardio-respiratory system is susceptible for the age-related changes: in cross-sectional studies the aerobic capacity has acknowledged declining around 10% per decade and the longitudinal studies have emphasized that the decrease accelerates at older ages (Fleg &
Strait 2012). A low age-related cardiorespiratory capacity may overload an employee
and in long-term cause negative consequences. That kind of work tasks is, for instance, lifting and carrying external loads, which is needed in the nursing occupation. Thus, the physical demands should be decreased especially with the increasing age and regular exercise should be maintained to keep the person‘s cardiorespiratory capacity at a minimum in the age-related average level. (Ilmarinen 2001, 547)
A person reaches normally the maximum level of the muscular strength during a young adulthood and the strength levels start normally to decline with the advancing age (Ilmarinen 2006, 41, 118). According to the follow-up study, the maximal isometric trunk extension and flexion strength of ageing male employees decreased by 40-50 % during the ten years follow up period (Nygård et al. 1999). Over 45-years old persons‘
physical work capacity has on average declined around 20 – 25 % compared to the person‗s lifetime best physical work capacity (age 25). In practice, the decline means, that the work-related demands should be lowered with around 20 % to promote or maintain employee‘s work ability and avoid overloading. The physical workload may be decreased by organizing lighter tasks, shortening the work week or the length of the work shifts. (Ilmarinen 2006, 41, 118; Ilmarinen 2001, 547)
2.3.3 Physical fitness
A good physical fitness promotes a person‘s work ability and capability to operate in the nursing. A physically strong person may not experience the same level or amount of stress factors (load) as demanding as a physically weaker person (Hänninen et al.
2005, 44) and that may increase the worker‘s perceived work ability. Based on the study by Nuikka (2002, 111), a good aerobic physical level of the individual has associated with lower level of loading at the nursing occupation. It has also acknowledged that sedentary lifestyle has acknowledged impacting strongly to lower perceived work ability among nursing personnel (Estryn- Behar et al. 2005).
Among paramedics‘ work, the muscle strength and function of the cardiorespiratory system have perceived as the most important factors to have capabilities to work in the physically demanding occupations (Vehmasvaara 2004). Instead, among home care workers, the obesity, weak strength in abdominals, weak balance and weak strength in the upper body were the most significant factors to predict the decreased work ability
isometric knee extension and moderate capacity of maximal oxygen uptake (VO2max) were also remarkable risk factors for decreased work ability in the future. (Pohjonen 2001a)
A physical work ability/capacity can be improved by regular physical exercising since a regular physical exercise program has proven to improve the capability to cope with the work-related physical stress factors (Suominen 1997, 17). The UKK Institute's Physical Activity guidelines for 18-64 years old people suggest being active various days in a week which include activities that improve aerobic fitness for total at least 2.5 hours of moderate level activity or instead of doing vigorous activity 1 hours and 15 minutes a week. Also, health-enhancing physical activity includes activities to improve person‘s balance and muscular strength at least two times in a week (UKK Institute 2009). In this study, we researched how the study population fulfilled the current recommendations for health-enhancing physical activity according.
2.3.4 Health status
The person‘s health is one of the most important resources of the person; health forms the basement for the worker‘s work ability together with a functional capacity (Ilmarinen 2006, 80-81, see more 2.1.11). According to Downie and colleagues (1991, 9-10, 25), the health can be viewed from the negative and positive viewpoints. From the positive viewpoint, a health means physical, mental and social well-being but also physical fitness and notion of true-well-being. Instead, the negative viewpoint of health compromises the prevalence of diseases, disabilities, illnesses or injuries. In this study, the health was viewed from the negative and positive perspectives: we acknowledged that health and physical fitness forms the basement for the work ability and is the biggest resource of person‘s work ability. Indeed, we examined the prevalence of MSDs. Hence, the study viewed the health also from the negative viewpoint.
The individual‘s overall health may impact on employee‘s capabilities to tolerate with the work-related demands; various diseases may decrease the individual‘s physical capabilities and thus, the possibility to cope with the work-related demands decrease (Takala 2007, 48-49). Also, the decreased health may cause functional rejections, which may in turn decrease the work ability. The limitation of work ability due to the disease or injury is depended on the exact work environment, organization and content of the
work but also other resources of the individual. The diseases which weaken the physical capacity may decrease the work ability of the employee who operates in physically demanding occupation – instead, the occupations without high physical demands may not be limited due to diseases. (Koskinen et al. 2006a, 130) For instance, the practical nurses work-related characteristics may vary from light organising tasks to providing care for disabled and elderly people which include lifting and transfers (Appendix 1).
In Europe, the musculoskeletal disorders (MSDs) are the most widespread occupational- related diseases. Repetitive work, awkward and uncomfortable (constrained posture) and excessive or prolonged muscular work load increase the risks of developing MSDs, especially in arms and hands and in the neck/shoulder areas. (EU-OSHA 2010, 13) Even more than a quarter of all occupational level nurses in the studied ten European countries have reported having some musculoskeletal disorder diagnosed by a physician (Estryn-Behar et al. 2013, 98). Most common MSDS among nursing personnel have reported being neck-and shoulder disorders and back problems (Azma et al. 2016;
Engels et al. 1994a; Cheung et al. 2018; Kröger et al. 2009, 42). Also, some studies have referred that the high prevalence of knee problems among nursing professionals are common (Heiden et al. 2013; Mehdad et al. 2010; Cheung et al. 2018).
The prevalence of self-associated back problems has indicated to increase from the point the nurse starts the education and continuous to working life: at the baseline, 31 % of students experienced to suffer from back pain and after the graduation, 72 % of nurses perceived to experience back pain. After the five years of follow-up time and operating as a nurse, the prevalence of back problems was associated among 82 % of the nurses. (Videman et al. 2005) As Videman and colleagues (2005) pointed out, although it is not doubtless to confirm that the increased number of back pains are caused or due to nursing occupation, still the increasing number of the back pains seems to increase during working in the nursing occupation. Most often reported MSDs among nursing students have been low back pain, neck and shoulders disorders and problems in lower limbs (Smith & Leggat 2004; Smith et al. 2003; Smith et al. 2005).
The obesity may threaten and decrease the possibility to work in physically demanding occupations (Koskinen et al. 2006b, 151). According to National Study of the Adult Finnish Population (ATH, 2016), 17 % of working age women and 22 % of working
men are obese (BMI ≥ 30 kg/m2) (Murto et al. 2017). Also, overweight or obesity may cause more likely musculoskeletal disorders. Zhao and colleagues (2012) acknowledged that one third of nurses experienced low back pain (LBP) during the two years observation time and the most significant risk for LBP was among obese and overweight nurses.
The person‘s health status and work ability can be for instance, assessed by the number of sick leaves (Laine et al. 2011, 112). The practical nurses have acknowledged having on average 26 sick leave days annually which is high compared to other municipal workers in Finland. (FIOH 2017a) The high amount of sick leave days among practical nurses is concerning according to the well working services but the consequences of sick leaves are also expensive for the society. The sick leaves, disability pensions and work-related accidents and other factors which decrease the populations‘ work ability, cause annually around 40 milliard euros expenses in Finland (Kauppinen et al. 2013, 5).
Those expenses could be decreased by developing and maintaining the work ability of the employees and guaranteeing that the work demands are not higher than the employee‘s resources. Furthermore, nurse‘s health status has acknowledged to differ from average population because according to the gathered results of the systematic literature review, nurses have increased risk for musculoskeletal disorders, but also tuberculosis, breast cancer and they are also more vulnerable to blood borne pathogens (HIV, hepatitis A, B and C- virus) than the average population (Fronteira & Ferrinho 2011).
2.4 Methods to assess a person’s physical work ability
Physical performance tests are appropriate methods to predict the worker‘s future work ability especially among the workers who operate in physically demanding occupations (Suni 2001, 76-78). Because the individual‘s resources and the demands of the work fluctuate during the time, the balance between worker‘s resources and work-related demands should be assessed regularly (Ilmarinen 2006, 8; Hanhinen et al. 1994, 28).
According to the Finnish Occupational Health Care Act (1383/2001 12§), employer has a responsibility to arrange the occupational health care to assess and investigate regularly the healthiness and safety of the certain workplace but also to assess and investigate the worker‘s health, work capacity and functional capacity.
Physical capability of the person has normally assessed by the measurement of body composition (e.g. fat percentage and BMI), but also as a capacity and well-being of the respiratory, -circulatory and musculoskeletal systems. Respiratory and blood circulation system (aerobic) can be assessed in multiple ways, for instance, by using the UKK walk test or bicycle ergometer test. Instead, the person‘s musculoskeletal health can be assessed by the endurance and maximal strength of the main muscle group. According to the objectives, the applied measurement tool can be different test batteries (PFTB), dynamometers, EMG- analysis, or by using free weight or person‘s own body weight.
(Savinainen et al. 2007, 73) For instance, the study called ―Health, functional capacity and welfare in Finland 2011‖ have provided an objective knowledge about Finnish populations‘ physical fitness level and it has acknowledged predicting well the future health and functional capabilities of the population. The tests included the following physical tests: balance (standing with one leg), 6-minutes walking tests, jumping tests (peak force production) and push-up test. The study revealed that male persons maintained better fitness level in all tests compared to their counterparts. Instead, between age groups (old-young), the biggest difference was in balance tests and the minors in the walking test. (Suni et al. 2012 125-175)
A person himself/herself can also assess the current state of work ability with questionnaires and interviews (Ilmarinen et al. 2006, 32). That kind of methods are, for instance, Work ability index (WAI) (Tuomi.et al.1992) or the limitations of the work performance (Schellekends et al. 2010). Also, the person may assess the physical capability by comparing the own physical level to the same aged people (Savinainen et al. 2007, 73). Furthermore, the prevalence of MSDs can be reported as musculoskeletal complaints during one year (Kuorinka et al. 1987) and according to the rejections in work performances due to musculoskeletal symptoms (Tuomi et al. 1992).
Also, the work management may evaluate the employee‘s performance in the actual work environment and social insurance officers usually assess the worker‘s health status and functional abilities. The health care sector utilizes normally clinical methods to assess a person‘s physical capabilities his/her ability to cope with the work-related demands. The clinical methods are normally and especially used in the situation when the person‘s work ability is decreased. (Ilmarinen et al. 2006, 32) Instead, in an
assess the individual‘s resources, plan the rehabilitation process, estimate the physical capabilities and/ or follow the effects of work ability intervention (Lindholm &
Ilmarinen 2007, 220-221).
In this research, the physical work ability is assessed by self-perceived health status, physical fitness and well-being of the musculoskeletal system according to the practical nurses‘ experiences/assumptions of the occupation‘s physical requirements and exposure to physical stress factors. As an assessment method, we utilized a questionnaire.
3 THE KNOWLEDGE OF WORK-RELATED DEMANDS IN NURSING In the following section, we take a closer look for the demands in nursing occupation and the possible methods to assess physical load in the occupation. Furthermore, we summary the discussed literature and framework of the study.
3.1 The characteristics of practical nurses
The practical nurses are the largest occupational group in the social and health care sector and hence, they have a significant role to promote all aged people‘s health, well- being and development (Simberg & Nevala 2016, 5). The most important task of the practical nurses is to support the patient/customer in daily living but in the future, the systematic promotion of person‘s health and well-being becomes more crucial (Hakala et al. 2011, 71). The characteristics of practical nurse‘s work are highly depended on the surrounding work environment because practical nurses may operate in different working environments at the social and health care sector but also in an educational sector (Vuori-Kemilä et al. 2005, 15; Nevala & Simberg 2016, 7). Thus, also the required competencies differ between the workplaces (Hakala et al. 2011, 52). In Appendix 1, we have defined precisely the characteristics of certain workplace according to the specialisation program of the education.
In 2014, in Finland, there were all in all 147 630 working practical nurses with a protected occupational title. When comparing the amount with the beginning of this century, the number of practical nurses has increased by more than 44 500 employed practical nurses. (THL 2018a, 36) Every year around 10 000 new practical nurses graduate from the Vocational education in social and health care. For instance, in year the 2015, all in all, 9921 practical nurses graduated from the education (TEHY 2017, 19). The occupational title of practical nurse is protected in the Health Care Professionals Act (L 559/94) and only the person who has accomplished the Vocational Education in Social and Health Care has a right to use the title. In Finland, National Supervisory Authority for Welfare and Health (Valvira) supervises the working at the occupation and grants the right to the profession upon application. In Finland, the social and health care sector is predominantly female occupation: around 90 % of practical nurses in Finland are women (THL 2018a, 43) and currently, the average age of the
3.2 Knowledge concerning practical nurse’s work-related demands
For the next, we will clarify the presence of main physical, psychological and social demands in the nursing occupation. We also define the organizational factors which may have an impact on the work-related demands.
3.2.1 Physical demands
The nursing has been acknowledged as a highly physically demanding occupation (Trinkoff et al. 2003) which includes handling of heavy external loads, for instance, repositioning, lifting and transferring patients or clients (Pohjonen et al. 2003, 16;
Estryn-Behar et al. 2003). The physical stress factors and exposure to them are perceived to differ between the social and health care departments in Finland; in the elderly homes and inpatient wards, the work is expressed at the most physically demanding. That is mostly due to a high amount of patient transfers in elderly homes and in-patient wards. In those departments, 70 % of the social and health care staff have expressed the need to carry, lift and hold over 25- kilogram external loads many times during a work shift without lifting- or other mechanical aids. (Laine et al. 2011, 30) For instance, in a nursing home, nurses have reported performing on average 27 patient transfers during each work shift (Freitag et al. 2012). Therefore, according to the earlier knowledge, in this study, we acknowledged that the variations in the perceived level of the physical load measured by RPE-scales may vary due to nurse‘s work environment.
Moreover, lifting of an external object is more demanding in the care occupation than in any other professions; the external object to lift is a real person which requires also other professional skills from the worker, for instance, interaction skills with the patient/customer (Hanhinen et al. 1994, 46).
In addition, the occupation includes postural demands; nurses need frequently work in uncomfortable postures, bent and twisted, and nurses perform also a high amount of incline movements (Hignett 1996; Lagerström et al. 1998; Estryn- Behar et al. 2003, 94;
Freitag et al. 2012). The most common prevalence of the bad postures may happen when the nurse helps or supports the patient/customer to wear clothes, for instance, sock and shoes, assist in showering, does patient transfers and makes the bed (Hanhinen et al.
1994, 43; Engels et al.1994). For instance, around 45 % of Finnish and French nurses have reported working continuously in the constrained working postures over six hours
a day (Estryn-Behar et al. 2003, 97). Also, the occupation is strenuous for the upper body since nurses must perform work as upper extremities elevated above the 30° level (Torgén et al. 1995). That stresses highly the person‘s neck- shoulder area, especially when lifting patients without using supporting instruments (Hanhinen et al. 1994, 42-43, 47). Moreover, working with the patients may in some occasion require working on knees or in a squat position (Karhula et al. 2007, 17). For instance, 15 % of Finnish social and health care staff has reported working on knees or in a squat position at least 1-2 hours in a day (Perkiö-Mäkelä et al. 2006, 81). Working on knees may be a risk for a person‘s musculoskeletal health, because thus, 70 % of an individual‘s body mass is loaded to the knees which increase the inner load of the joints. It has acknowledged that working on the knees or in a squat position may cause or increase the prevalences of the knee pains, knee osteoarthritis and bursitis of the patella. (Riihimäki 2001, 158–161) Moreover, constant walking and upright position during work shifts may be physically demanding. The amount of standing and walking varies between the care occupations and health care departments; often less educated nurses walk more during a workday than higher educated nurses. Around 80 % of the French and Finnish nursing assistants have reported prolonged standing (>6 hours) during a work shift. (Estryn-Behar et al.
2003, 97) Continuous standing loads especially the spinal column but also joints in a lower extremity and slowdowns the blood flow in the lower limbs (Hanhinen et al.
1994, 52).
3.2.2 Psychological demands
Besides the high physical demands in the social and health-care sector, the ever- increasing psychological demands are challenging issue currently and, in the future (Kauppinen et al. 2010, 228-229). The work-related psychological demands can be defined, for instance, as a lack of feedback, no possibility to influence own work, unclear objectives, high amount of work, need to hurry, high emotional load, a lack of respect, no possibilities to develop in the occupation or the requirements are excessive according to the employee‘s skills and experience (Lindström et al. 2005, 38-39;
Pohjonen et al. 2003, 16; Hanhinen et al. 1994, 80). According to Sinervo (2000, 67), it seems to be obvious that psychological, but also social (3.2.3) factors have an impact on the level of physical demands in the occupations. For instance, most of injuries or
problems due to non-ergonomic performances can be explained because of the high time pressure in the work environment. Although the rush and high amount of work are normally related to psychological demands, in this paper, we emphasize them in the section of organizational factors (3.2.4).
Work in the social and health care sector includes normally the high responsibility of other person and challenging decision makings which may be psychologically demanding (Laine et al. 2011, 16; Hanhinen et al. 1994, 103). In the Finnish social and health care sector, the complex nature of problem-solving and decision-making was reported as the most demanding in the social sector, in mental health and in substance abuse welfare work (Laine et al. 2011, 16). In the future and currently, the decision- making may become more challenging because of the structural changes in Finland as the elderly are more and more supported to live at their home environment. Thus, the working environment of the nurses may be increasingly targeted to patient‘s/customer‘s home and it may cause that a nurse needs to make decisions and solve aroused problems more independently. (Hakala et al. 2011, 90) Also, nursing is highly emotional; nurses meet and work with patients/clients but also with their families‘ emotions (Fronteira &
Ferrinho 2011).
As the demands in the social and health care sector have widely acknowledged to increasing in the future and the sector is constantly changing, the prevalence of the stress may become more common. Stress may have harmful consequences and be a risk for employee‘s health and safety. (Portoghese et al. 2014, 152) The stress has investigated to increase the mistakes in work performances and therefore, decrease patient safety (Elfering et al. 2006). Also, stress may have negative effects on an individual‘s well-being and decreases the productivity and successful work and its outcomes, increase the number of sick leaves and increase the risk for depression (Moreau et al. 2004; Vahtera et al 2010; Wang 2005).
3.2.3 Social demands
Harmful social stress factors at the workplace are normally caused by the insufficient relationship or collaboration with the co-workers but also due to defective leadership/management. Possible problems among colleagues may be bullying, continuous need to work without support, - and cooperation or interaction with the co-
workers which causes regularly negative feelings. (Lindström et al. 2005, 44-47; FIOH 2017b) A good cooperation in the work environment is important because it may promote and increase the work satisfaction and reduce the feelings of stress but also helps to find solutions for aroused work-related problems (Kivimäki et al. 2002, 47).
The surrounding atmosphere of work community may impact on individual‘s work ability. The employee is motivated to work in an acceptable and constructive work environment although the employee would have physical rejections, diseases or injuries.
In contrast, in a negative work atmosphere, small rejections might experience to be insurmountable and cause decreased work willing and work ability. (Korppoo 2006, 181) The perceived support, positive feedback, healthy relationship, flexibility, for instance, in work times, clear objectives and support from the manager may protect the staff from the burnout (Vartiovaara 1996, 200-201; Korppoo 2006, 184). For instance, more than 40 % of the practical nurses have perceived not to receive enough support from the closest manager (Kröger 2009, 39). The support and positive feedback are important because they may increase the self-confidence and self-esteem of the employee, which in turn increase the work success and person‘s work capabilities (Vartiovaara 1996, 198).
Also, the high risk of violence in the social and health-care sector is a prominent problem. In most cases, the risk of violence is highest among the intoxicated customers and their family, in first aid and emergency work but the risk of violence also exists with children and dementia persons. Also, the increased amount of home care has increased the risk of violence. (MSAH 2008, 26-28) In the Scandinavia, every fifth practical nurse has experienced to encounter violence or risk for it daily or at least weekly (Kröger 2009, 41). Among Finnish practical nurses, 72 % of nurses have encountered violence or risk for it at the workplace over the last year (Erkkilä et al.
2016, 14).
3.2.4 Organizational factors
Organizational arrangements may have an impact on work-related physical and psychosocial demands either by increasing or balancing the load. The organizational factors can be defined as work environment-related factors: a content of the work, the
instance, the surrounding work environment, its design, technique and availability of supporting tools impact on how much muscular work is needed and what kind of movements and postures are required during the work shift. Also, the temperature, lighting and noise, work time, break arrangements, the tightness and disorder in the work environment may have an impact on the level of the physical demands and exposure to them. (Hanhinen et al. 1994, 30; Kähkönen 2001, 192-193; Olkinuora 2001, 195-197)
A great haste at the work environment increases the risk that nurse work and lift patients/customers with a poor posture and with a bad technique (Tamminen-Peter &
Wickström 1998, 19). The need to hurry has reported high especially among employees who work in the health-care centres and in elderly care as 60 % of respondents expressed to experience often or constantly the need of hurrying. Moreover, the home care workers experienced the most often feelings of rushing. (Laine et al. 2011, 34) The need to rush is normally caused by a lack or inappropriate amount of staff in the work shift which has reported as regular among practical nurses‘ occupation (Kröger 2009, 40; Erkkilä et al. 2012, 22). Therefore, nurses must, for instance, perform patient lifts without support from other nurse and that may be a risk for nurse‘s work ability and musculoskeletal well-being (Hänninen et al. 2005, 111).
Instead, nurses may not always have lifting aids available in the operating environment to use them to promote or help in lifting and transferring patients (Cowley & Leggett 2010). The availability of technical lifts in Finland has reported as low when comparing the results with other European countries; only around one of third of nursing personnel in Finland reported to have technical lifts available (Estryn-Behar et al. 2013, 96;
Kröger et al. 2018, 34). Instead, 46 % of Finnish home care workers express to have availability to use supporting tools in physically demanding work tasks (Kröger et al.
2018, 34).
A shift work is common among social and health care workers, almost 40 % of social and health care workers do shift or period-based work in Finland (Hakola et al. 2007, 11). A shift work may be a hazard to social and health care employees due to various negative physical and psychological impacts on workers‘ health. A shift work has reported to increase, for instance, likelihood of accidents, exhaustion, interpersonal
