Relationship between mental workload and musculoskeletal disorders with intention to leave service among nurses working at neonatal and pediatric departments: a cross-sectional study in Iran

Leaving the service refers to the attrition of an organization’s workforce during a certain period of time [1]. Intention to leave the service is a cognitive stage that occurs before the actual turnover and is defined as the mental decision-making about leaving or staying in the service [2]. Nurses’ intention to leave the service has been reported 3–75% at the international level [3]. One study reported nurses’ intention to leave the service as 32.7% in Iran. In another study, this rate was 54.6% [4, 5]. Leaving the service is among the major reasons for lack of human resources in the health system, which has become a challenging and international problem [6]. The organization for economic cooperation and development (OECD) reported more than 3.2 million nurses will be needed by 2030 [7]. Leaving the service causes the loss of efficient and competent nurses [8], affecting the quality of care and services provided to patients [9]. Investigating the etiology of this phenomenon is complex, especially in healthcare settings, because it could be influenced by motivational, cognitive and behavioral factors. Moreover, the factors associated with nurses’ intention to leave service could be divided into two categories, i.e., individual and organizational factors [10]. Previous studies have identified various factors influencing nurses’ intention to leave the service. In short, good salary, good relationship with the manager and appropriate benefits were associated with less intention to leave the service, while excessive absenteeism, work stress, burnout, service dissatisfaction and workload were associated with higher nurses’ intention to leave the service [11, 12]. Among the above-mentioned factors, service dissatisfaction was the most important one, which was associated with service stress, shortage of nursing staff, increased patient-to-nurse ratio, burnout and nurses’ high workload [13]. Workload is a general concept, which includes both physical and mental workload, analyzing which separately could provide different results regarding the intention to leave the service. The physical workload of nurses is defined as physical skills such as moving and transferring patients and administering medicine [14]. Mental workload is a multidimensional and multifaceted concept, which is defined as the effort made by the mind while performing tasks. In other words, mental workload refers to the intellectual and cognitive requirements or analytical efforts made by employees while performing tasks at a specific time and place [15]. Mental workload includes receiving, understanding and interpreting information, making decisions, concentrating and interacting with patients and their families [16]. Studies have reported mental workload as 70.21% and 56.4% among Indonesian and Chinese nurses, respectively [17, 18]. The mental workload of emergency nurses and nurses caring for patients with COVID-19 has been reported as 85.42% and 67.14%, respectively, in Iran [19, 20]. Increased mental workload is associated with workforce’s fatigue and injury, which could affect nurses’ clinical performance [20]. Moreover, mental workload is among the psycho-social factors that could affect physical aspects such as work-related musculoskeletal disorders [21, 22]. Musculoskeletal disorders are associated with psychological stress as well as physical workload [23]. Work-related disorder is among the categories of musculoskeletal disorders, which has been investigated in different work environments such as administrative, manufacturing and healthcare settings [24‐26]. The prevalence of musculoskeletal disorders has been reported as 48.1–95.7% among different societies [27‐29]. This disorder is prevalent among healthcare staff and is more prevalent among nurses and physiotherapists [23, 30]. Musculoskeletal disorders are highly prevalent among Iranian nurses [31, 32], especially in the back, neck, upper back, knees, ankles, hands, shoulders, hips, thighs and elbows [33]. Furthermore, the nature of nurses’ profession exposes them to fatigue and diseases, especially musculoskeletal disorders [34]. The nursing profession consists of different subgroups, in each of which nurses perform different tasks under different working conditions. Pediatric nursing is one of these subgroups, in which nurses provide appropriate and quality care for children in acute and chronic care units [35]. Although working in other wards such as emergency room/ward is more associated with physical and musculoskeletal disorders, it seems necessary to examine working conditions in pediatric wards because pediatric nursing actions like blood sampling, catheterization, tracheal intubation, etc. are often performed under inappropriate conditions [36]. Poor cooperation with nurses in providing care due to parents’ excessive concern about their sick children [37], lack of agreement on pain management and necessity of assisting patients with activities like eating, dressing and bathing make taking care of children more challenging than taking care of adults [38]. Musculoskeletal disorders have acute and chronic physical consequences, which often affect other aspects of health and well-being. Some functional consequences could be easily identified such as taking analgesics to cope with symptoms, while others affect life quality at work and home, and are more likely to reduce or change work tasks and recreation [39, 40]. In addition to physical factors, it has been reported that pediatric nurses have high mental workload [37]. Most of nurses working at pediatric intensive care units have reported temporal demand, cognitive load and psychological stress as the major workload components [41]. Moreover, working at crowded clinics with children in different age groups on a tight schedule could also affect pediatric nurses’ intention to leave the service [42]. In addition to taking care of sick children, pediatric nurses also take care of their family members in some way. In Iran, the majority of pediatric nurses are women who become strongly emotional due to their sense of motherhood when caring for critically ill children and observing their parents [43]. Nurses feel distressed when performing painful procedures on children and describe it even as “torture” for their patients [44]. When caring for adults, communication is often established between the medical team and patients, so that patients could directly involve in treatment and declare their agreement/disagreement with the treatment process. However, when taking care of children, communication is established between the child, parents and medical team. In some cases, parents are more involved in choosing treatment strategies due to the prevalence of patriarchal culture in Iran and children’s preferences are less considered. Furthermore, conflicts between children and parents’ and caregivers’ demands may cause moral tensions in providing child care [45]. Being precise and sensitive and having high concentration to provide nursing care to children and infants are of particular importance, so that any negligence could lead to irreparable consequences. Facing such stresses and tensions, the need to go back and forth to the patient’s bed and frequently visit the sick child, and nature of providing nursing care to children for a long period of time, which often causes them to be in improper ergonomic positions, may affect nurses’ mental workload, physical health and intention to leave the service. However, a limited number of studies have been conducted in this filed. Consequently, since it is necessary to perceive the intention to leave the service and potential effective factors for planning, policy making and performing appropriate interventions in order to maintain specialized human resources, this research was conducted to determine the relationship between the mental workload and musculoskeletal disorders and intention to leave the service among nurses working at neonatal and pediatric departments in Bushehr Province, during 2022 to 2023.

Demographic questionnaire included information such as age, marital status, educational level, body mass index, history of vitamin D deficiency (self-report), having children, age of the youngest child, hospital and department name, employment status, nursing experience, number of night shifts, monthly overtime hours and type of work shifts.

National aeronautics and space administration-task load index (NASA-TLX): This questionnaire is a multi-dimensional assessment tool, which evaluates and measures the perceived mental workload in order to assess a specific task or activity. NASA-TLX consists of subscales of mental demand, temporal demand, physical demand, performance, effort and frustration.

These subscales are explained as follows:

Mental workload(demand): How much mental and cognitive activity was required? Was this task easy or difficult, simple or complex?

Physical workload(demand): How much physical activity was required? Was this task easy or difficult? Was it followed by rest or did it require intense physical activity?

Temporal demand: How much time burden did you feel based on the speed of performing each activity? Did the activity progress quickly or slowly?

Performance: How successful were you in performing the goals of the task? How satisfied were you with your performance?

Frustration level: How much did you feel discouraged, irritated and stressed during work, instead of feeling secure, relaxed and satisfied?

Effort: How hard did you have to work mentally or physically to reach the desired performance?

This tool includes two parts: In the first part, each subscale is scored from 0 to 100 based on a 5-point scale. Each subscale is presented as a 10 cm line with a title, e.g., temporal demand. The top point is expressed by a bipolar descriptor (high/low). Among the six NASA-TLX subscales, three subscales contribute to the needs imposed on the nurse when performing physical, mental and temporal tasks, and three subscales are related to the result of performing the task, i.e., personal performance, level of effort and level of failure and frustration. Except for the performance subscale which is assessed based on good and bad options, other subscales are evaluated based on low and high options. Explanations are provided for each of these six subscales, which should be read by users before scoring. In the second part, a pair-wise comparison is made between these subscales in 15 modes, and the participant specifies the subscale that has the most impact on them. The total mental workload score is obtained by multiplying the score of each subscale in the first stage by the corresponding weight in the second stage (number of times each subscale is chosen), which is then divided by 15. The scores below 50 are considered acceptable and scores above 50 are considered high [46, 47]. Mohammadi et al. (2013) confirmed the face and content validity of this tool. Its internal consistency reliability was obtained as 0.84 using Cronbach’s alpha method, indicating appropriate reliability [48].

Cornell musculoskeletal discomfort questionnaire (CMDQ): This questionnaire was organized in three parts: Discomfort frequency, severity of pain and effect on work power during the last working week [43, 44]. CMDQ consists of a map depicting 12 body parts (in total, 20 regions of the body). This questionnaire is designed in standing and sitting positions both for men and women. The standing questionnaire has been localized and includes three parts of discomfort frequency, severity of pain and effect of pain on work power. Scores could be analyzed by weighting the scores to identify the most serious problems. Discomfort frequency is first specified by scoring never (0), 1–2 times a week (1.5), 3–4 times a week (3.5), every day (5) or several times a day (10). Then, weighting is done by multiplying the above-mentioned score (0, 1.5, 3.5, 5, 10) by discomfort (1, 2, 3) and interference (1, 2, 3) scores. Thus, the score of each part of the body ranges from 0 to 90. Based on CMDQ scoring, musculoskeletal disorders are divided into three general categories: Trunk, upper and lower limbs. The questionnaire’s validity and reliability were confirmed by Oğuzhan Erdinç et al. (2008). The reliability of frequency, severity and interference was obtained as 0.876, 0.895 and 0.875 using the test-retest method, respectively, indicating high CMDQ internal consistency [49]. Kashani et al. (2009) confirmed face and content validity of this tool, and its reliability was obtained as 0.98 using Cronbach’s alpha method. Cronbach’s alpha coefficients of discomfort frequency, severity of pain and effect of pain on work power were obtained as 0.95, 0.96 and 0.96, respectively [50].

Voluntary turnover intention scale: This scale was designed by Mobley and Horner (1978) based on a five-point Likert scale, so that the items are scored from 1 (completely disagree) to 5 (completely agree). This scale consists of three items. The lowest and highest scores are 3 and 15, respectively. The construct validity was assessed by Mobley et al. (1978) and the results showed the scale has adequate construct validity. The scale Cronbach’s alpha was reported as 0.90 [51]. Abid et al. (2017) in Pakistan calculated reliability as 0.86 using Cronbach’s alpha [52]. Also, the scale validity and reliability were confirmed by Hashemi et al., in Iran so that the reliability was reported as 0.89 [53].