American Association for Physician Leadership

Strategy and Innovation

Shift Work and Low Back Pain in Nurses Working in an Emergency Department in Italy: Which Targets for Organizational Interventions?

Gabriele d’Ettorre | Vincenza Pellicani | Mariarita Greco

December 8, 2017


Low back pain (LBP) is the most common musculoskeletal disease affecting nurses and the most common cause of work-related disabilities worldwide; a growing literature has revealed a trend toward increased rates of LBP in healthcare workers in Western countries, and, consequently, increasing economic costs related to LBP. The aims of this study were to analyze the relationship between shift work and acute LBP among female shift RNs in an emergency department, and to detect preventive interventions directed toward organizational issues.

Interventions aimed at preventing musculoskeletal disorders (MSDs) among healthcare workers (HCWs) are of interest throughout the world, as MSDs have become increasingly frequent and, consequently, the economic costs related to their occurrence have increased. According to epidemiologic data, HCWs are particularly exposed to the risk of MSDs, and low back pain (LBP) is the most common cause of work-related disabilities among nurses.(1-4) The literature reveals a trend toward increased rates of LBP in HCWs in Western countries due to both: (1) aging of the general population and, consequently, an increased number of people needing healthcare; and (2) a demographic change that is resulting in people working to a greater age and consequent high risk for intervertebral disk degeneration in older workers.(5-7)

A growing literature points to the need for workplace policy development related to organizational issues as a strategy that can help to minimize the occurrence of LBP in the healthcare sector. Rasmussen et al.(8) showed that participatory interventions aimed to minimize organizational risk factors (e.g., lack of communication or bad communication between supervisors and employees or colleagues in between) and psychosocial risk factors (e.g., low prioritization of staff well-being, conflicts with the person who needs care) should be prioritized, with the aim of minimizing the occurrence of MSDs. Many authors have shown that, among other psychosocial risks, shift work, including night work, is linked with the occurrence of LBP in registered nurses (RNs).(9-11) Hopcia et al.(12) observed an increased risk of injury (not including needlestick and sharps injuries) in RNs with more consecutive work days and longer cumulative working hours, and demonstrated the need for organizational interventions targeted to shifts as a strategic way to better protect the safety and health of workers.

Shift work also has been linked with a greater risk of increased body mass index (BMI) and central obesity(13-15) as a consequence of circadian rhythm disruption and unhealthy lifestyles (e.g., poor dietary habits, low recreational physical activity, sleep deprivation). These findings evidenced the need for occupational health programs directed at lifestyle factors (e.g., promotion of physical activity, healthy diet), aimed at the prevention of musculoskeletal and other noncommunicable diseases.(16-19) Despite these findings, to date there has been little evidence about the impact of shift work, including night shift, on the occurrence of acute LBP among RNs working nontraditional shifts, including nights and 12-hour shifts. The purpose of our research was to analyze the impact of shift work, physical activity, and BMI on the occurrence of work-related LBP (WRLBP) among female, rotating-shift RNs in an emergency department, with the aim of suggesting organizational interventions that would be effective in minimizing the occurrence of WRLBP.


We conducted a matched case-control study that included all the female rotating-shift RNs employed in an emergency department in Salento, Italy (n = 694; mean age: 45.1 ±1.9; years of work: 21.4 ±2.5). The study, performed from January 2016 to December 2016, was aimed at analyzing:

  • The relationship among cumulative hours, night shifts, and WRLBP;

  • The relationship between forward-rotating shift schedules (morning-afternoon-night) and WRLBP occurrence; and

  • The relationship among BMI, physical activity, and WRLBP.

Study of the shifts worked prior to the date of WRLBP analyzed:

  • The total number of hours worked in the previous 7 and 28 days;

  • The total number of nights worked in the previous 7 and 28 days; and

  • The direction of rotating shift schedules in the 28 days prior to the date of WRLBP.

A shift was categorized as a night shift if it included the hours of 1:00 AM and 2:00 AM. Cases were selected according to the following case definition for WRLBP:

  • Activity-limiting LBP (± pain referred into one or both lower limbs) that lasts for at least one day;

  • “Low back” defined as the area on the posterior aspect of the body from the lower margin of the twelfth ribs to the lower gluteal folds(20); and

  • Acute LBP that occurred at work.

If the RNs reported more than one WRLBP incident, all the cases of WRLBP were included in the study. Controls were randomly selected from the registry database of shift RNs working in the same hospital, with similar demographic characteristics (e.g., unit type, job type, gender, age ± 5 years) and not already included in this study as cases. Each case was matched with two controls. All of the cases and the controls were RNs who worked rotating shifts in an emergency department in which the occupational risk assessment detected high levels of patient manual handling risk for shift RNs.(5) Cases and controls were divided according to:

  • The number of night shifts worked 7 and 28 days prior to the day of WRLBP;

  • Total hours or shifts worked 7 and 28 days prior to the day of WRLBP;

  • BMI;

  • Leisure physical activity; and

  • Adoption of constant forward-rotating shift schedules 7 and 28 days prior to the day of WRLBP.

BMI was categorized, according to the standard World Health Organization (WHO) definition,(21) as normal if between 18.5 kg/m2 and 24.99 kg/m2; overweight if between 25 kg/m2 and 29.99 kg/m2; and obese if 30 kg/m2 or more. Leisure physical activity was defined as the equivalent of 2 1/2 hours of moderate to vigorous physical activity each week, in leisure time; in fact, the WHO recommends that all adults should get at least that much physical activity to maintain good health.(22,23) The authors used the Occupational Prevention and Protection Service database consisting of all incident and safety reports (including the occurrence of WRLBP) and Human Resources information. The study population is reported in Table 1. The statistical analysis consisted of a logistic regression to calculate incidence odds ratios with 95% confidence intervals. The chi-square test and t-test were used to examine the relationship between categorical and continuous data, respectively. All analyses were performed using SPSS for Windows. The study was performed as part of the obligatory evaluation of WRLBP required by Italian Legislative Decree 81/08, and needed no formal approval by the local ethics committee.


In the period investigated, 97 cases of WRLBP were reported among the 684 female RNs (annual incidence = 14.2%); three of the subjects reported more than one episode of WRLBP. No significant differences were found among cases and controls compared by cumulative hours and total shifts worked in the 7 and 28 days prior to the date of the injury causing acute LBP. A significant risk of LBP was found for nurses working for more than two 12-hour shifts in the previous 7 days, compared with those working fewer than three 12-hour shifts in the previous 7 days. Cumulative night shifts were significant for three or more night shifts compared to working fewer than three night shifts in the previous 7 days (OR = 3.82 ; 95% CI = 1.19-12.26); additionally, WRLBP was more common among RNs working more than eight night shifts than for those working fewer than four night shifts in the previous 28 days (OR = 3.45; 95% CI = 1.83-6.53) (Table 2). The adoption of constant forward-rotating shift schedules proved effective in preventing acute LBP compared with shift schedules that did not follow the constant forward-rotating model in the preceding 28 days (OR = 0.30; 95% CI= 0.18-0.51; p <.05) (Table 3). Less leisure time physical activity was reported among cases than controls (p <.05) and showed as a protective factor for WRLBP occurrence (OR = 0.35; 95% CI = 0.20-0.62; p <.05). The cases were more often obese than controls, and an increased odds ratio for acute LBP was found among obese RNs (OR = 2.73; 95% CI=1.30-5.80) (Table 4).


The analysis showed the relation between shift work and WRLBP, and, consequently, the need to strategize regarding the best way to approach the concern. In fact, increased odds ratios for WRLBP were found for RNs working night shifts more than 3 or 9 nights, respectively, in 7 and 28 days. These findings confirmed the evidence in the literature regarding the harmful effect of shift work, including night shift, on workers’ safety. In the past, many studies demonstrated the link between shift work and occupational stress, burnout, fatigue, sleeping difficulties, reduced work efficiency, poor performance, decreased job satisfaction, increased rates of absenteeism and turnover, and increased accident and injury rates.(24-26) In our study, night shift work was confirmed as a workplace stressor for shift RNs working frequent night shifts—a stressor that could be minimized through organizational interventions aimed at reducing the number of night shift per RN to be no more than 3 nights a week and no more than 9 nights every 28 days. The risk of WRLBP was found to be increased among RNs working three or more 12-hour shifts a week or working more than six 12-hour shifts every 28 days; this finding demonstrated the unhealthy impact of extended shifts on the workers’ safety, in accordance with many authors(12,24-27) who have pinpointed such extended shifts as a major risk for the occurrence of occupational injuries. This finding may be due to increased fatigue, poor mood, or poor recovery from work between work periods, all of which have been linked to long work hours.(26-29) Extended shifts followed by several days off allow workers to better manage schedules outside of work, but represent a risk for occupational acute LBP.

A forward-rotating schedule for rotating shifts proved effective at better protecting the workers’ safety than a backward-rotating schedule or other rotating schedules.

In accordance with HSE recommendations,(30) the adoption of a forward-rotating schedule for rotating shifts proved effective at better protecting the workers’ safety than a backward-rotating schedule or other rotating schedules; in fact, we observed a trend of increasing odds ratios for acute LBP in RNs adopting rotating schedules other than forward-rotating shift work.

These findings showed that RNs with a heavy night workload and frequent extended shifts may incur a greater risk of WRLBP; organizational interventions targeted at reducing the shift load (e.g., reducing the number of night shifts worked to fewer than three a week and fewer than nine monthly, limitation of extended shifts, adoption of a forward-rotating schedule) are required to moderate the shift workload and, consequently, to minimize the occurrence of WRLBP among RNs in emergency departments (Table 5).

The analysis of BMI revealed that cases were more often obese than controls, and obesity was associated with a high risk of WRLBP (OR = 2.73; CI = 1.30-5.80); these findings confirmed the evidence reported by many authors(18,19) in reference to the relationship between shift work and increased BMI, and showed that obesity is a risk for the occurrence of WRLBP among female RNs.

This study supported the need to prioritize interventions aimed at promoting healthy lifestyle choices and targeting modifiable lifestyle factors (e.g., alcohol consumption, smoking, physical activity), with the aim of preventing noncommunicable diseases and, particularly, the occurrence of WRLBP among rotating shift work RNs.


Shift work and WRLBP were found to be interconnected. Improvement interventions should be aimed at: (1) moderating the organizational risks linked with shift work schedules; and (2) promoting healthy lifestyles. These interventions are suggested as a strategic way to effectively manage the phenomenon among female rotating shift RNs in emergency departments. According to the World Health Organization, constructing healthy workplaces, including in the healthcare sector, is a goal that may be reached through collaboration between workers and managers, with the aim of promoting and protecting the health, safety, and well-being of all workers and the sustainability of the workplace.(31)

The study has some limitations:

  • The period investigated is too short to draw strong conclusions about the relationship between shift work schedules and occurrence of WRLBP.

  • The analysis was conducted on a small sample.

  • The study is targeted to the relationship between WRLBP and cumulative hours, night shifts, forward-rotating shift schedules, BMI, and physical activity, and does not take into account other types of determinants for WRLBP; and

  • The disadvantage of case-control studies is that they do not indicate absolute risk, but, rather, the risk of the category worked related to another lower or referent category.


  1. Freimann T, Pääsuke M, Merisalu E. Work-related psychosocial factors and mental health problems associated with musculoskeletal pain in nurses: a cross-sectional study. Pain Research and Management. 2016;

  2. Duthey B. Background paper 6.24: low back pain. World Health Organization. 2013. .

  3. Sadeghian F, Hosseinzadeh S, Aliyari R. Do psychological factors increase the risk for low back pain among nurses? A comparing according to cross-sectional and prospective analysis. Saf Health Work. 2014;5:13-16.

  4. Lin PH, Tsai YA, Chen WC, Huang SF. Prevalence, characteristics, and work-related risk factors of low back pain among hospital nurses in Taiwan: a cross-sectional survey. Int J Occup Med Environ Health. 2012;25:41e50

  5. Battevi N, Menoni O, Alvarez-Casado E. Screening of patient manual handling risk using the MAPO method. Med Lav. 2012;Jan-Feb;103(1):37-48.

  6. Sharma S, Shrestha N, Jensen MP. Pain-related factors associated with lost work days in nurses with low back pain: across-sectional study. Scand J Pain. 2016;11:36-41.

  7. Lorusso A, Bruno S, L’Abbate N. A review of low back pain and musculoskeletal disorders among Italian nursing personnel. Ind Health. 2007;45:637-644.

  8. Rasmussen CD, Holtermann A, Jørgensen MB, Ørberg A, Mortensen OS, Søgaard K. A multi-faceted workplace intervention targeting low back pain was effective for physical work demands and maladaptive pain behaviours, but not for work ability and sickness absence: Stepped wedge cluster randomised trial. Scand J Public Health. 2016;44:560-570.

  9. Wagstaff AS, Sigstad Lie JA. Shift and night work and long working hours—a systematic review of safety implications. Scand J Work Environ Health. 2011;37:173-185.

  10. Stimpfel AW, Brewer CS, Kovner CT. Scheduling and shift work characteristics associated with risk for occupational injury in newly licensed registered nurses: an observational study. Int J Nurs Stud. 2015;52:1686-1693.

  11. Attarchi M, Raeisi S, Namvar M, Golabadi M. Association between shift working and musculoskeletal symptoms among nursing personnel. Iran J Nurs Midwifery Res. 2014;19:309-314.

  12. Hopcia K, Dennerlein JT, Hashimoto D, Orechia T, Sorense G. A case-control study of occupational injuries for consecutive and cumulative shifts among hospital registered nurses and patient care associates. Workplace Health Saf. 2012;60:437-444.

  13. Pepło´nska B, Bukowska A, Sobala W. Association of rotating night shift work with BMI and abdominal obesity among nurses and midwives. PLoS ONE. 2015;10(7): e0133761. Published online 2015 Jul 21. DOI: 10.1371/journal.pone.0133761.

  14. Pepło´nska B, Bukowska A, Sobala W. Rotating night shift work and physical activity of nurses and midwives in the cross-sectional study in Lodz, Poland. Chronobiol Int. 2014;31:1152-1159

  15. Pepło´nska B, Burdelak W, Krysicka J, et al. Night shift work and modifiable lifestyle factors. Int J Occup Med Environ Health. 2014;27:693-706.

  16. Zhao I, Bogossian F, Turner C. The effects of shift work and interaction between shift work and overweight/obesity on low back pain in nurses: results from a longitudinal study. J Occup Environ Med. 2012;54:820-825.

  17. Pepło´nska B, Burdelak W, Krysicka J, et al. Night shift work and modifiable lifestyle factors. Int J Occup Med Environ Health. 2014;27:693-706.

  18. Buchvold HV, Pallesen S, Øyane NM, Bjorvatn B. Associations between night work and BMI, alcohol, smoking, caffeine and exercise-a cross-sectional study. BMC Public Health. 2015;15:1112.

  19. Tada Y, Kawano Y, Maeda I, et al. Association of body mass index with lifestyle and rotating shift work in Japanese female nurses. Obesity (Silver Spring). 2014;22:2489-2493.

  20. Weaver MD, Patterson PD, Fabio A, Moore CG, Freiberg MS, Songer TJ. The association between weekly work hours, crew familiarity, and occupational injury and illness in emergency medical services workers. Am J Ind Med. 2015;58:1270-1277.

  21. WHO. Physical status: the use and interpretation of anthropometry. Report of a WHO expert committee. WHO Technical Report Series No. 854.

  22. Harvard T.H. Chan School of Public Health. The Obesity Prevention Source. .

  23. World Health Organization. Global recommendations on physical activity for health. .

  24. Caruso CC, Condon ME. Night shifts and fatigue: coping skills for the working nurse. Am J Nurs. 2006;106:88.

  25. Caruso CC, Waters TR. A review of work schedule issues and musculoskeletal disorders with an emphasis on the healthcare sector. Ind Health. 2008;46:523-534.

  26. Caruso CC. Negative impacts of shiftwork and long work hours. Rehabil Nurs. 2014;39(1):16-25.

  27. Dwyer T, Jamieson L, Moxham L, Austen D, Smith K. Evaluation of the 12-hour shift trial in a regional intensive care unit. Nurs Manag. 2007;15:711-720.

  28. van der Hulst M, van Veldhoven M, Beckers D. Overtime and need for recovery in relation to job demands and job control. J Occup Health. 2006;48(1):11-19.

  29. van der Starre RE, Coffeng JK, Hendriksen IJ, van Mechelen W, Boot CR. Associations between overweight, obesity, health measures and need for recovery in office employees: a cross-sectional analysis. BMC Public Health. 2013;13:1207.

  30. Health and Safety Executive (UK). Managing Shiftwork—Health and Safety Guidance. London: HSE; 2006. .

  31. World Health Organization (Geneva). Healthy Workplaces: A Model for Action. 2010.

Gabriele d’Ettorre

Local Health Authority of Brindisi, Director of the Health Unit of Occupational Prevention and Protection, Piazza Di Summa, 72100, Brindisi, Italy; e-mail:

Vincenza Pellicani

Department of Mental Health, Local Health Authority, Lecce, Italy.

Mariarita Greco

Local Health Authority, Brindisi, Italy.

Interested in sharing leadership insights? Contribute

This article is available to Subscribers of JMPM.

Log in to view.

For over 45 years.

The American Association for Physician Leadership has helped physicians develop their leadership skills through education, career development, thought leadership and community building.

The American Association for Physician Leadership (AAPL) changed its name from the American College of Physician Executives (ACPE) in 2014. We may have changed our name, but we are the same organization that has been serving physician leaders since 1975.


Mail Processing Address
PO Box 96503 I BMB 97493
Washington, DC 20090-6503

Payment Remittance Address
PO Box 745725
Atlanta, GA 30374-5725
(800) 562-8088
(813) 287-8993 Fax



AAPL providers leadership development programs designed to retain valuable team members and improve patient outcomes.

American Association for Physician Leadership®

formerly known as the American College of Physician Executives (ACPE)