Nurses are highly exposed to risks of work-related disorders and injuries, culminating in burnout and low quality of care [1]. Such injuries may involve all body organs, especially the musculoskeletal system [2]. Musculoskeletal disorders (MSDs) refer to health problems affecting the locomotor apparatus, such as the skeleton, muscles, tendons, cartilage, ligaments, and nerves [3]. MSDs comprise several degenerative and inflammatory conditions affecting the joints, tendons, ligaments, muscles, peripheral nerves, and supporting blood vessels, leading to soreness and physical discomfort [3].

Among health care workers, nurses have a higher risk of developing work-related musculoskeletal disorders (WMSDs) [4]. Nurses play pivotal roles within the health care system, which can be physically challenging as they frequently help patients to mobilize, transfer between positions, and execute other daily life activities [5]. Multiple factors have been found to increase the risk of WMSDs among nurses, including physical load and work posture [6], psychosocial factors such as the presence of psychosomatic symptoms and personality, work tasks, and work organizational factors [5]. Thus, it is not surprising that nursing staff stationed in the operating room recorded a higher prevalence of occupational injuries compared with intensive care nurses, nonspecialized nurses, and radiologic technicians [7]. Events including static body posture, prolonged standing, using tools such as retractors during surgery, and manual tasks such as pushing, pulling, and lifting patients and surgery sets could elicit discomfort and WMSDs, particularly among nurses working in operating units [8]. Recent studies have also highlighted factors such as low educational level, increasing age, high BMI, and lifestyle as predictors of WMSDs among nurses [4].

Given the aforementioned points, several authors have advocated and explored effective workplace interventions to address the risk of WMSDs among nurses. Occupation-specific interventions and rehabilitation options have the potential to reduce functional disabilities among nursing staff that may result from these injuries [8,9]. Ergonomic interventions, particularly participatory ergonomics (PE), are a promising approach to reducing WMSDs. PE integrates large-scale interventions that are performed at organizational and systems levels with small-scale interventions where workers are opportune to use their knowledge in addressing work-related ergonomic issues [8]. It entails the active involvement of workers in controlling and planning a significant amount of their tasks or work activities while introducing ergonomic knowledge, changes, and procedures in order to enhance working conditions, productivity, safety, quality, and comfort [9].

Positive outcomes such as lower musculoskeletal symptoms and occupational injuries, improved psychological health, as well as a decrease in workers’ compensation claims, productivity loss, and work absenteeism, were reported following PE interventions among various high-risk groups [9,10]. Despite ergonomic interventions being considered essential to reduce the increasing trend of WMSDs, there is no agreement or consensus on the most appropriate intervention, as the component and approach may vary with the workplace setting [[11]].

The risk of WMSDs can be predicted based on ergonomic, individual, and psychosocial factors [8]. Ergonomics scientifically discusses how a job can be aligned with a person’s physical and psychological characteristics without causing any harm to the person’s well-being and efficiency [11]. The onset and development of WMSDs can be prevented by acquiring more knowledge and applying ergonomics [12]. Nurses are motivated to become more efficient, experience higher job satisfaction, and reduce job-related stress, occupational-related diseases, accidents, and absenteeism when they work in appropriate ergonomic conditions [13].

An earlier study revealed several advantages and enhanced occupational health among community nurses following the implementation of a multifaceted ergonomic program [14]. Moazzami et al [15] reported that alterations in nurses’ body movements were facilitated by ergonomic educational intervention, particularly from the contemplation and preparation phases to the action phase for adopting correct body postures in the operating room. Likewise, a significant reduction in musculoskeletal pain in the shoulder, neck, and knee regions was recorded among nurses in general wards after implementing an ergonomic educational intervention [16]. The use of ergonomic posture training among nursing assistants also led to a significant reduction in work-related low back pain 6 months after the intervention but did not affect disability scores [15]. However, some studies depicted limited success of ergonomic interventions on measured outcomes such as WMSDs [16,17], work productivity, and absenteeism [18], which may be linked to differences in the design of interventions, samples, data collection tools, settings, and research design. Thus, there is still limited information on the appropriate and effective ergonomic interventions for preventing and addressing WMSDs and their related consequences among nurses.

Although more research is required to develop conclusive evidence on the effectiveness of ergonomics interventions in reducing WMSDs among nurses, pertinent information is yet to be gleaned from the several available studies in the literature. In the last decade, numerous studies have demonstrated the importance of diverse programs such as participatory, educational, single, and multidisciplinary ergonomics interventions among nursing professionals [12,19,20]. Nevertheless, findings from these studies are yet to be systematically reviewed. Most of the systematic reviews focused on office workers or workplace settings [21] and dental and health care professionals [22]. However, Sun et al [23] in a recent systematic review and meta-analyses, compared the efficacy of nondrug interventions on nonspecific low back pain among nurses and found that the most effective intervention was a combination of low back exercises and health education, followed by single low back exercises and yoga.

Previous literature reviews have investigated the effectiveness of interventions among nurses and in nurses’ homes [14], including nursing assistants’ risk of handling obese and overweight patients and interventions to reduce low back pain [24]. However, none of the past reviews looked into how ergonomic interventions ameliorate WMSDs and their consequences, particularly among nurses. The present review differs from prior attempts by systematically analyzing the various ergonomic interventions adopted in preventing WMSDs and other closely related outcomes, including sickness absenteeism and work performance or productivity in nurses. It seeks to provide evidence-based data and scientific support for developing an ergonomic intervention to prevent WMSDs among nursing professionals.

The objective of this systematic review is to assess the effectiveness of ergonomic interventions in preventing WMSDs and mitigating two related outcomes, sickness absence and work performance, among nurses.

This systematic review was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. The PRISMA statement was developed to assist researchers in preparing a complete, accurate, and transparent review that is beneficial to users [25]. The PRISMA 2020 statement includes new reporting guidelines, particularly for systematic reviews of studies that appraise the effects of health interventions. The PRISMA statement was considered suitable for the present systematic review, given its provision for a clear definition of research questions, identification of the exclusion and inclusion criteria, and assessment of relevant and accessible scientific papers within a specific timeframe. In addition, this review has been registered in International Prospective Register of Systematic Reviews (PROSPERO) with the registration number CRD42023403981.

Formulation of a concise and clear research question is an important phase to guide the authors in many aspects of the systematic review. PICO, a research question development tool (RQDT), was used in the formulation of the research question for this review. PICO is an acronym in which P is population, I is intervention, C is comparison, and Ois outcome, and the 3 main concepts of PICO are population or problem, interest, and context. The authors of this review made an effort to incorporate all the aspects in synthesizing the main research question. Considering the population of interest as nurses, ergonomic intervention as the intervention, other nonergonomic interventions as the comparison group, and WMSDs, work performance, and sickness absenteeism as the outcomes, the research questions for this systematic review are as follows:

Systematic review is part of a module development.Module development has obtained study ethics approval from the Medical Research Ethical Committee of Universiti Malaya Medical Centre (MREC ID No:20221019-11632) and National Medical Research Register (NMRR ID-23-01804-F44).

The initial search process before filtering and screening resulted in a total of 5867 papers, comprising 525 from PubMed, 1009 from Scopus, 1617 from ScienceDirect, and 2716 from PsycNet (Figure 1). Upon considering the years of publication (2017‐2023) and language (ie, English), the remaining papers were reduced to 2166 (ie, PubMed=363, ScienceDirect=504, Scopus=528, and PsycNet=771).

Thereafter, 1160 papers were identified as duplicates and removed accordingly. To further reduce the number of records, the remaining results from each database were sorted and subjected to title screening. Out of the remaining papers (n=1006), those with irrelevant titles (n=616) and abstracts (n=346) were removed, leading to a total of 44 papers for full-text reading. Around 25 studies were excluded after reading the full texts because of irrelevant study populations (ie, not involving nurses or health care professionals, n=8), not reporting any ergonomic intervention (n=3), unclear study design (n=2), qualitative study designs (n=4), and ergonomic interventions with WMSDs as primary outcomes (n=8).

Overall, 19 papers were experimental studies involving ergonomic interventions among nurses and other related health care professionals. These papers reported at least one of the following outcomes: WMSDs symptoms or pain, sickness absence, and work performance. Hence, all 19 papers were included in the final analysis and systematically reviewed. Table S1 in Multimedia Appendix 1 depicts the studies and participants’ characteristics of types of ergonomic interventions and a summary of the main findings.

As shown in Table 2, 7 categories of ergonomic interventions were identified in the 19 studies as follows: (1) exercise and physical activities, (2) educational programs, (3) health promotional activities and training, (4) patient handling devices or equipment (acquired ergonomics equipment), (5 programmes) workstation and administrative interventions (organizational management), (6) counseling, and (7) others (case management and transcutaneous electrical nerve stimulation). The predominant ergonomic intervention was exercise and physical activities (11/19, 58%), followed by health promotional activities and training (8/19, 42%), educational programs (7/19, 36%), patient handling devices (4/19, 21%), workstation and administrative interventions (n=3), counseling (n=3), and case management (n=2). Furthermore, 3 studies reported specific exercises for back pain, 2 for neuromuscular pain, and 1 for neck pain. Around 10 studies (53%) each entailed either only multicomponent or single intervention, whereas 1 study compared both types of interventions.

Despite the heterogeneity of the 19 studies in this review in terms of study design, interventions used, sample size, measured outcomes, and research instruments, we were able to identify the participatory ergonomic interventions designed specifically for nursing professionals. In addition, the research designs and results revealed the methodological quality of the studies and evidence of the interventions in ameliorating WMSDs among this high-risk group of health care workers.

Descriptive findings from the systematic review revealed that the predominant PE interventions, specifically for preventing and managing WMSDs among nurses, were physical activities or exercise, health promotional activities, educational programs, and patient handling devices. These findings are consistent with previous systematic and integrative reviews focusing on interventions to address WMSDs and their secondary outcomes among health care professionals [43,44]. Physical activities and specific exercises are frequently considered in PE interventions either as individual or multifaceted approaches, given their efficacy in reducing musculoskeletal pain and associated symptoms [44]. Educational programs and health promotional activities are also integrated with most multicomponent interventions to enhance nurses’ knowledge, attitude, and self-efficacy toward lifestyle changes and behaviors to mitigate risk factors of WMSDs [43,45].

Single or individual interventions were applied in 10 studies ranging from physical activity to educational programs and the use of patient handling devices. Nevertheless, contradictory findings were gleaned from the studies, with few reflecting a low to moderate reduction in WMSD risk and ergonomic risk scores following educational programs [8,36]. Ergonomic exercise (ie, neuromuscular and back exercise) conducted in 3 studies also led to significantly lower scores for low back pain [40] and overall body pain scores [16,31]. These findings corroborate reports of individual exercise and physical activity proposed by Jakobsen et al [34] for the generality of health care professionals. Several prior studies have equally emphasized the positive effect of physical exercise on MSDs [20,29]. Moreover, physical exercise helps in preventing recurring and new episodes of WMSD pain [46], improving endurance, strength, and neuromuscular control in rehabilitation patients [47]. In contrast, 3 studies found no significant preventive effects of single interventions such as educational programs, individual-based interventions, and patient handling devices in ameliorating WMSDs among nurses and health care professionals [17,34,37]. These studies reflect the need for a multifaceted approach to addressing musculoskeletal pain, especially when designing interventions that include educational ergonomics. In other words, rather than using educational programs in isolation, they should be combined with other interventional approaches such as exercise.

As observed in this review, several studies entailed multifactorial interventions—a combination of procedures considering numerous factors and events acting on multiple levels [48]. This approach aligns with the multifaceted causes of WMSDs [19], which require integrated and comprehensive management strategieseducational program rather than isolated approches [42]. Comparisons between multicomponent and single interventions depicted that the former was more effective in reducing the risk of WMSDs among nurses relative to single type of ergonomic interventions. These results were evidenced in several studies involving a combination of health promotion activities and case management [19], workstation adjustment and training [10,28], educational ergonomics and patient handling equipment [39], as well as those involving physical activities and exercise [29,32,38]. In addition, moderate to high effect sizes were reported in studies where multicomponent interventions included at least one or more physical activities and exercise, whereas effects in those without exercise were generally low to moderate. These findings are consistent with a recent review conducted among health care professionals, in which the strongest reduction in WMSD injuries and pain stemmed from combined manual or mechanical patient lifting and handling training [44]. This could be explained by the fact that exercise, patient handling devices, and ergonomic training offer opportunities to mitigate physical risk factors and insufficient handling knowledge, which are the main contributing events to injuries among nurses and health care professionals [49,50]. More importantly, these studies highlight the significance of multifaceted PE aimed at comprehending the appropriate handling of patients or using the principles of biomechanics in executing such activities [30] and guidelines implementation [18]. These findings align with the Occupational Safety and Health Administration recommendations for increased availability of assistive facilities and devices, including both sophisticated and basic devices, that are crucial for safe patient handling [40].

Only a few reviewed studies investigated work performance and sickness absence, which may be because these events are secondary outcomes of WMSDs. This finding is not surprising, given that a systematic review of RCTs aimed at reducing sickness absence among health care workers identified only 7 relevant papers [45]. Results from the present review highlight the need to further explore how nurses’ work performance and sickness absence can be improved by ergonomic interventions. Most studies found no significant effects of multicomponent and individual interventions on these secondary outcomes at different follow-up points [19,28,32]. For instance, complaints of low back pain and its associated cost persisted among nurses for several weeks and months after performing neuromuscular exercise and back care counseling [32].

These studies raise the question of whether some multifaceted PE interventions, such as ergonomic education, health promotion activities and case management, neuromuscular exercise, and back care counseling, are either productive or counterproductive in improving secondary outcomes primarily linked to WMSDs among nurses. On the contrary, reduced work-day absences and increased safe patient handling were observed in health care professionals subjected to task-specific and multifactorial interventions such as mechanical and practical in-ward activities [50]. These promising results from studies conducted among health care workers emphasized changing the work dynamics, increasing job satisfaction, productivity, and the complicity between workers [32]. Moreover, psychological stress constitutes approximately 28% and 84% of upper back injuries in health care professionals [51].

Although qualitative studies were not included in this review, results from the studies highlighted the importance of considering psychological health problems, ergonomic knowledge, and preventive behaviors that could shape the risk of WMSDs, sickness absence, and work performance [11,18]. Organizational, physical, psychosocial, and personal factors were found to play pivotal roles in the development of musculoskeletal problems and their related consequences, thereby supporting the use of multifaceted interventions. Hence, as recommended by Carneiro et al [52], the organizational aspects of the working environment have to be considered in order to address WMSDs and their direct consequences on nurses’ health and productivity.

Multiple approaches are required to effect changes in practices and encourage a safety culture, such as ongoing training, skills, workflow processes, supervision, and communication between health care professionals about the risks [43,44]. This diverse and multifaceted approach is also crucial considering that long-term adherence to interventions is necessary for sustainable positive impacts on WMSDs, especially their secondary outcomes. For instance, although nurses enduring from WMSDs can experience significant relief following a short-term ergonomic intervention, a prolonged duration is required for the effects on sick leaves and performance [45]. Hence, the long-term beneficial effects of adhering to these multicomponent interventions need to be analyzed and relentless efforts to effect the necessary changes are equally important [41].

Quality assessment results underscored various areas to be considered when interpreting the systematic review findings. For instance, moderate and high risk of bias was observed in 5 and 8 studies, respectively. Thus, only 6 papers were of high quality. Methodological issues identified in the studies mainly entailed limited information on participants’ baseline characteristics, potential confounders that may affect the intervention’s effect, not addressing missing data, incoherent onset of intervention and follow-up, and poor adherence to the intervention regimen. These findings highlight the need for well-designed and high-quality RCTs.

The strength of the systematic review stems from being among the first attempts to gather current evidence on ergonomic interventions for nursing professionals and their effects on WMSDs, sickness absence, and work performance. In addition, a comprehensive and systematic approach was used, thereby assisting the researcher in retrieving relevant papers from selected databases. Quality appraisal was also performed to identify the methodological gaps that need to be bridged in future research. Nevertheless, the limitations are well acknowledged. Given that only papers published between 2015 and 2023 were considered in the review, papers published before these dates might contain important findings that are relevant to the research topic. The literature search and screening processes were performed only by the principal investigator, reflecting the possibility of bias and unknown intraobserver reliability. Moreover, only papers written in English in 4 databases were considered, thus limiting relevant studies written in other languages that might have assisted in answering the review questions.

This systematic review synthesized evidence published between 2017 and 2024 on ergonomic interventions to reduce WMSDs and sickness absence and improve work performance among nurses. The most common interventions entailed physical activities or exercise, educational programs, health promotional activities, and training on the usage of patient handling devices or equipment, which were usually applied either as a single or multicomponent approach. Overall, the findings suggest that multifaceted interventions are more effective in reducing the risk of WMSDs and the associated pain in nursing professionals compared with individual interventions. The strongest effect size was observed in multicomponent interventions comprising at least one or more physical activities and exercise. Although these positive results are expected to lead to improved work functioning, work performance, and reduced sick leaves, available results are convincing to support the use of either single or combined ergonomic programs in achieving these secondary outcomes.

Apart from conducting high-quality RCTs, addressing the identified research gaps requires the integration of organizational factors and prevention policies to enhance psychological health, job satisfaction, and work dynamics into multicomponent ergonomic interventions. Since most interventions are designed for short-term periods, efforts to ensure their long-term effects are crucial for sustainable positive impacts on WMSDs, sickness absence, and work performance. For instance, introducing curricula content on the management of WMSDs and improving work performance, sickness absence and psychological health in nursing education may assist nurses in adopting the measures discussed in this review in clinical practice. This review may guide health care institutions on the most appropriate ergonomic interventions to prevent or reduce WMSDs among nurses, given their significance for well-being and economic implications in terms of absenteeism, work performance, and care for clients enduring mobility problems.