Introduction:

Chronic pain is a global health problem and known as a frequent or continuous period of pain, which can last longer than expected duration. This time is considered to be at least 3 months for research objectives¹. In the United States, the prevalence of chronic pain in the adult population is reported to be between 14.6% and 64%². It is also common in Europe and its treatment imposes high burden on people, employers, health care systems and the community as a whole³. Chronic pain is a severe, prolonged and debilitating condition, which significantly decreases the health status of people and the quality of life of them⁴. It is considered as one of the major causes of suffering and disability in the world⁵. This type of pain can affect various aspects of the person and cause emotional, behavioral and functional disabilities. Evidence suggests that unwanted consequences such as depression⁶, anxiety and emotional disorders are associated with long-term outcomes of sustained pain such as physical disability, work disability⁷, increased health care costs⁸, death⁹ and suicide^10. In Europe, out of five patients with chronic pain, one person lost his job due to pain and one third of the subjects suffered from chronic pain and its effects in some hours of work or whole of it¹¹. Studies suggest that high indirect economic and social costs are associated with chronic pain in Europe and America^3,12.

Nursing is recognized as one of the high-risk jobs in terms of development of disorders and diseases¹³. The results of some studies have shown that nurses experience more functional restrictions compared to other two job groups. They also complain of continuous and prolonged pain in most parts of their body, while the mean age of these three job groups was not the same¹⁴. In this regard, some studies have only examined the differences in psychological factors in the two groups of nurses who had a disorder during the last one month, compared to those who had a disorder during the last one year¹⁵ and even in studies conducted with the aim of evaluating the prevalence of chronic pain in the general population, despite the difference in the onset of pain among the population studied, the factors affecting the inclusion of subjects in different groups have not been examined¹⁶. By gaining this type of knowledge, we can identify the people who are exposed to pain earlier than others and take some steps in order to reduce or delay the onset of pain in this group. Therefore, considering the effects of chronic pain and the effects of existing disorders on nurses' job performance and their ability to provide effective care in patients¹⁷, the prevalence of chronic pain needs to be evaluated in nurses. In addition, given the working conditions of this group of people, it is necessary to recognize the time of the onset of chronic pain and factors affecting it. In this regard, based on the available research literature, no study was found to evaluate the prevalence and associated factors of chronic pain in this job group. Thus, this research was conducted to evaluate the prevalence and associated factors of chronic pain in nurses Iran. We hope that the results of this research to be useful in improving the conditions of the nurses and providing high quality care for them.

Materials and methods:

Participants and methods.In this cross-sectional study, the participants included all nursing staffs working in educational hospitals in Bandar Abbas in 2017. In some studies, total population has been examined. In this study, all 710 nursing staffs with master and bachelor level of education were invited to participate in the study. The inclusion criterion of the study included: 1) having more than one year of clinical employment history. Exclusion criteria of study: 1) included people who have left the work or were absent in work place for any reason and 2) Unwillingness to participate in the study. Finally, 639 people were included in the study.

Data collection:The data collection tool in this research was a structured, self-administered questionnaire (based on a review of the literature^2,18,19 of the experts' studies and views). It included three parts: The first part included demographic information of nurses such as age, gender, marital status, level of education, job experience, type of work place, type of employment, work shift and job position. The second part consists of two questions, including the presence or absence of continuous pain and the onset of pain (in the last 2 weeks - last one month -last 3 months- more than 3 months- in the last 6 months- more than one year). It should be noted that chronic pain was considered as a pain lasting more than three months in this study, and the third part was a question about pain in different parts of the body (16 parts of the body were examined).

In order to examine the face and content validity of the research tool, the views of experienced professors and experts in this area were used and its validity was reported to be desirable. To calculate its reliability, the data collection form was given to 30 nurses as pilot. Finally, based on the internal correlation of the questions, the Cronbach's alpha was calculated to be 0.9 (p<0.05). Accordingly, reliability of the tool was reported to be desirable.

Data analyses: To analyse the data, SPSS 15 software was used. To describe the quantitative data, mean and SD were used, and to describe qualitative data, frequency and percentage of frequency were used. In order to determine the prevalence of chronic pain, all nurses were first examined and to determine the relationship between chronic pain and demographic variables, Chi-square, Fisher exact test and independent t-test were used. Then, Chi-square tests was used to determine the differences in the three groups of chronic pain patients with onset of pain in the more than three months ago, in the last six months and more than one year. Finally, binary nominal and multi-nominal logistic regression analyses were used to determine the effect of independent variables on chronic pain and onset of chronic pain.

Results:

The prevalence of chronic pain and associated factors:Results showed that out of 639 nurses, 459 subjects had continuous and recurrent pain, which onset of chronic pain in 414 of them (64.8%) was more than three months ago. Among the subjects, 67% were female and 31% were male. Their mean age was 36.46 ± 6.98, and 6.2% of them were married and 77.3% had bachelor level of education. In addition, the majority of subjects with chronic pain had work experience of 10 to 20 years and they were formally employed. More information is provided in Table 1. In addition, the chronic pains of low back (27.7%, [n=115]), leg (21%, [n=87]), neck (16.7%, [n=63]), head and knee (15.2%, [n=69]), and waist (7.2%, [n=30]), respectively, had the highest frequency among the nurses (Chart 1). In addition, chronic pain had a significant relationship with variables of gender, marital status, and level of education, type of employment, job position, and work experience (P<0.05) (Table 1). In designed models, in binary logistic regression, the variables such as age, gender, and type of employment were introduced as the predictors of chronic pain in nurses. (Table 2) shows the results of logistic regression analysis and odds ratios for the model variables at the confidence level of about 95%.

Chart 1. Frequency the types of chronic pain in nurses The quality of the figure must be improved

The design of the tables must be adjusted to the demands of the journal

Differences in the onset of chronic pain and associated factors: After examining the existing statistical differences between the three groups of nurses with a different onset of chronic pain, the results indicated that these three groups had significant differences in variables of job experience, type of employment, and age. More information is presented in (Table 3) (P<0.05). Moreover, after entering the variables into the multi-nominal logistic regression model, the results showed significant differences between people with onset of chronic pain more than 3 months compared to people with onset of pain more than one year in terms of job experience and unit where they were working (p<0.05). In addition, significant difference was seen between people with onset of pain in last 6 months and people with onset of pain in more than one year, so that the results showed that people with nursing job had onset of pain in more than one year ago, while people with supervisor job position had more onset of pain in last 6 months (P<0.05) (Table 4).

Discussion:

This cross-sectional study was conducted to determine the prevalence of chronic pain and the difference in the onset of pain and its related factors among nurses working in hospitals affiliated with Bandar-Abbas. The prevalence of chronic pain was reported 64.8%, indicating high prevalence of chronic pain in this job group compared to the general population^20,21. The highest frequency of pain was reported in low back, leg, neck, head and knee, respectively. Many studies have reported that low back pain is the most common pain in nurses^22,23, while the prevalence of other pains was also studied in this study. It should be noted that the scale used in the pain prevalence was different in different studies, but the results of this study were consistent with a number of studies, in which the prevalence of low back pain was higher than leg pain and neck pain, and knee pain^24,25. However, the results of some studies were inconsistent with the results of the present study regarding the prevalence of pain in the low back, leg and neck, which could be due to differences in the method of study, since they have examined merely acute pain and musculoskeletal disorders^26,14. Given the nature of nursing job and the high prevalence of musculoskeletal disorders and as the occurrence of these disorders can lead to continuous pain in these people, this group of people should be considered as one of the vulnerable groups exposed to chronic pain in different parts of the body and necessary measured should be taken to minimize this complication. In the present study, after performing multivariate analysis, three variables of age, gender, and employment type were identified as predictors of chronic pain in nurses. Many studies have reported the relationship between chronic pain and the age of people²⁷. The results of this study also showed that one year of increase in age increases the odds of chronic pain by 1.07.

In the study conducted by Feng et al. (2007) on chronic low back pain of nurses, in line with the results of the present study; this rate was reported 13.2%²⁸. Some studies have not showed association between age and chronic pain^29,30. It seems that this difference is due to differences in the studied population, so that only those with chronic pain disorder in one part of the body were selected as the research population. However, in the present study, nurses with chronic pain, without considering specific group, was considered as the research population. Results of the study indicate that chronic pain is also associated with gender^2,31 and it is two times more in females compared to males², while in the present study, it was reported to be 4.2 times more in females. Given that the majority of this job group are women exposed to chronic pain, this result can be justified. However, some studies have not reported such association³², which seems to be due to differences in the research population, so that only nurses working in surgical, intensive and emergency units were included in some studies, while in the present study, nurses of all units were examined. Another result of this study indicated an increase in the odds of development of chronic pain in people with formal employment status, compared to people with temporary employment status. This can be analyzed in several ways. As people with formal employment have mean age and a higher employment history compared to people with temporary employment status, they are more exposed to chronic pain and injuries caused by it. Moreover, as people with temporal employment status have more physical activity and working shifts, compared to those with formal employment status, but, people with formal employment status more suffer from chronic injuries and disorders³³. Among nurses with chronic pain, 15.2% of nurses reported chronic pain experience more than 3 months, 15.7% reported chronic pain experience more than 6 months, 69.1% reported chronic pain experience more than one year. One of the strengths of the present study is to examine the differences among different groups with different onset of chronic pain, since it helps us in identifying the vulnerable groups who experienced chronic pain for a longer time. In addition, research suggests a mutual and strong relationship between chronic pain and mood and emotional disorders in those who experienced pain for a long time³⁴. Therefore, by identifying these people, we can take necessary measures to develop preventive programs in order to reduce the duration of chronic pain in people and develop appropriate interventional programs for this group. The results of this study showed that people with more than 20 years of employment history, nurses working in intensive units for longer time, and those working as nurse in the units suffer from pain with onset of more than one year. Nurses working in clinical units¹⁹ are exposed to various musculoskeletal disorders due to working conditions, doing unusual movements in unusual positions such as repetitive movements, excessive workloads, prolonged sitting ups and sitting downs and carrying heavy burden³⁵. Additionally, psychological factors such as high demand, lack of control over occupation and lack of social support²⁵ are factors contribute to the development of disorders and disease, followed by chronic pain in this job group³⁶. Thus, the onset of chronic pin would be earlier in a person with longer employment history in the clinical setting and he or she would suffer from chronic pain for a longer period of time, which it can influence his or her activities^37,38. In addition, research shows that nurses working in intensive care units are more exposed to disorders and pain due to the characteristics of patients, the care of multiple intravenous lines, mechanical ventilation and other equipment, as well as activities related to patient care³⁹.

Conclusion:

The study indicates high prevalence of chronic pain in nurses. Iranian nurses complain of chronic pain in many parts of their body and the onset of pain is different among them. Thus, the professional problems of nurses should be considered. Knowing the factors affecting chronic pain and prolonging its duration in this group can help us develop preventive and educational programs. In addition, as nurses have a direct and close relationship with patients, adopting strategies before its development seems to be necessary based on the factors predicting the chronic pain and its duration.

Limitation: As most of the studies, this study suffers some limitations. One of the limitations was that nurses responded to questions in their workplace, so their stress and anxiety of the workplace could have affected their response. In addition, this study examined the prevalence of pain and its different onset and its relationship with demographic and job factors, while psychological factors were not considered. In addition, the present study did not examine the restrictions caused by chronic pain in these subjects, while other studies examined the restriction caused pain in one part of body. Further studies are recommended to examine other job reasons and psychosocial factors involved in development of chronic pain in this job group.

The researchers wish to express their gratitude to all participants for their participation in this research.

Conflict of interest: None declared

Agradecimientos

Acknowledgment: This study was the result of a master thesis submitted as a partial requirement of the master degree in nursing and approved in the ethics committee affiliated with Shiraz University of Medical Sciences (decree code: IR.SUMS.REC. 1396-01-08-14141).

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