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Experiences and expectations of return-to-work programs for nurses and midwives who have acquired a musculoskeletal disorder in the workplace

a qualitative systemic review protocol

Weckert, Christine1,2; Stern, Cindy2; Porritt, Kylie2

JBI Database of Systematic Reviews and Implementation Reports: May 2017 - Volume 15 - Issue 5 - p 1280–1287
doi: 10.11124/JBISRIR-2016-003002

Review question/objective: The objective of this systematic review is to identify and synthesize the best available evidence on the experiences and expectations of being involved in a program that aims to return nurses and midwives, who have acquired a musculoskeletal disorder (MSD) in the workplace, to work.

The specific review questions are:

  • What are the experiences and expectations of nurses and midwives involved in programs aimed to return them to work after acquiring an MSD in the workplace?
  • What are the experiences and expectations of coordinators involved in programs aimed to return nurses and midwives, who have acquired an MSD in the workplace, to work?

1Royal Adelaide Hospital, Adelaide, Australia

2The Joanna Briggs Institute, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, Australia

Correspondence: Christine Weckert,

There is no conflict of interest in this project.

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Musculoskeletal disorders (MSDs) are described in literature as injuries or disorders of the muscles, tendons, nerves, ligaments, joints, and cartridge with some expanding to include disorders of nerves, tendons, muscles supporting structures of the upper and lower limbs, neck, and lower back, where the underlying damage and changes cause discomfort, pain and disability due to inflammatory and degenerative conditions.1-4

Work-related MSDs are also referred to in the literature as “repetitive strain injury”, “back injury”, “tendinitis”, “sciatica” and “osteoarthritis”.2

Globally MSDs are one of the leading causes of morbidity and mortality, placing a burden on healthcare costs and resulting in an increased loss of time from work.1 Nurses in particular are at high risk for work-related MSDs due to the physically demanding nature of their work and the environment in which it is conducted.5 As a group, nurses have been recognized worldwide as the professional healthcare group with the highest incidence of manual handling-associated injuries.6 In 2011, US health personnel experienced seven times the national rate of MSDs compared with all other private sector workers.7 In Australia, 43% of all injury- and disease-related claims were related to acute and chronic MSDs.1 Muscular injury while lifting or handling objects caused 33% of serious claims in 2012–2013,5 and the median time lost in Australia from work for a serious claim rose by 29% from 4.2 working weeks in 2000–2001 to 5.4 weeks in 2011–2012.8

Workplace MSDs cause a huge financial burden to organizations. Economic costs relate to the direct costs of injury management, costs associated with injury investigations, the retraining and/or replacement of staff, equipment costs that may be required as well as the administrative costs in managing any claims.9 In 2012–2013, preliminary data show that there were 117,815 serious workers’ compensation claims in Australia.5 This equates to 11.1 claims per 1000 employees and 6.7 claims per million hours worked.5 The median compensation paid rose by 71% from $5200 in 2000–2001 to $8900 in 2011–2012.5

While MSDs in the workplace cost the Australian economy more than $60 million each year, it is important to remember the impact they can have at the social, human and organizational level.10 For the injured, the injury can have a profound effect on their relationships, psychosocial wellbeing and career.9 Some may be unable to continue working in their chosen career path.9

A qualitative study by Lydell et al.11 explored injured persons’ concerns about returning to their workplace following an MSD injury and how it affected them one, five and 10 years after the rehabilitation period. Three main categories emerged from this study with a total of nine sub-categories. They included motivation and optimism with three sub-categories of positive feelings: driving force, back to normal and new opportunities, and limitations to overcome, with three sub-categories regarding change: demand another job, need for adjustment and reduced work time, and hindrance and hesitation, with a further three sub-categories of pessimistic feelings: dejection, irresoluteness and bodily obstacles.11

Coutu et al.12 qualitative study in 2011 highlighted the impact MSDs have on people's lives, but the study was on participants who had no specific occupation. Central themes used by workers to describe health and illness were grouped as illness prototype, absence or presence of symptoms, physical health and capacity, engaging in health lifestyle, maintaining independence, preserving mental wellbeing, and healing from accidents and injuries.12

There is a social and economic interest in ensuring that the injured worker returns to work as safely and practically as possible following the workplace injury.10 To assist in this process, rehabilitation and return-to-work (RTW) programs were introduced in the late 1980s.13

Return-to-work programs assist injured workers to return to their workplace through early assessment, timely rehabilitation and modified duties.9 Many types of personnel including doctors, physiotherapists, occupational therapists, psychologists, ergonomists, case managers and coordinators can be involved in RTW programs.14 The length of RTW programs can vary in length from as little as one week through to multiple years depending on the severity of the injury. These programs are tailored to the individual staff member and dependent on the injury and their current workplace.10,15

The literature states that early intervention in the workplace for injured workers with the assistance of a RTW coordinator should reduce associated costs related to the backfill of positions and workers’ compensation.16 The RTW coordinator is involved in the coordination of the RTW process for the injured worker by planning an individualized RTW program, ensuring that the worker and the employee understands the process and communicate relevant information to both worker and employee and any stakeholder involved.17 Due to differences in jurisdictions, the coordinator of the RTW program may vary. Australia has both a primary public workers compensation system where a RTW coordinator is appointed from within the organization and a private insurance scheme where a privately hired RTW coordinator is appointed from a private organization. Internationally, some countries like the United States have unique private insurance schemes, while others like Canada may be solely public.17

In a 2007 literature review, the Canadian Institute for Work and Health concluded that RTW programs “have positive impacts on duration and costs of work disability”.17(p.5)

Research affirms the effectiveness of RTW programs in reducing workers’ compensation costs and significantly reducing work disability duration.13,18,19 The findings of a systematic review examining workplace-based RTW interventions demonstrated reduced work disability duration and associated costs; however, the evidence demonstrating the sustaining ability of these intervention was insufficient.20 There was also weak evidence to support the impact of these interventions on quality of life.20

A preliminary search of CINAHL, MEDLINE, the JBI Database of Systematic Reviews and Implementation Reports and the Cochrane Library revealed no systematic review specifically addressing the experiences and expectations of being involved in a program that aims to return nurses and midwives, who have acquired an MSD in the workplace, to work.

A qualitative systematic review on returning to work after injury by MacEachen et al.20 discussed the dimensions, processes and practices of RTW and how they can affect the success of RTW programs. The review was not specific to nurses and/or midwives or MSDs, and it did not focus on experiences and expectations of the injured nurses and midwives or those involved in coordinating their return to work.20

A review by Southgate concentrated on factors that facilitated or impeded the successful return of injured nurses to their workplace from the RTW coordinator's perspective only.16 Three key themes emerged from this review – workforce shortages, life circumstances and the impact of qualifications and specialization experience, and job security.16

Reviews found in the Cochrane Library were more broadly conducted in the area of MSDs and workplace interventions.21-24 Two systematic reviews examined the effectiveness of RTW programs but were specific to back pain in the general working population.25,26 Another review, examining qualitative evidence, was specific to MSDs; however, this review included health professionals broadly and did not specifically examine the experiences and expectations of the injured nurse or midwife.8 None of the reviews examined the role of the RTW coordinator.

The current systematic review aims to extend the knowledge of injured nurses and midwives and RTW coordinators’ experiences and expectations, and assist with establishing evidence-based practices for returning nurses and midwives with a work-related MSD back to their place of practice.

The current systematic review therefore seeks to understand injured nurses and midwives and RTW coordinators’ experiences and expectations of being involved in a program that aims to return nurses and midwives, who have acquired an MSD in the workplace, to work.

The purpose of this qualitative systematic review is to collate and synthesize the international evidence and apply it to practice.

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Inclusion criteria

Types of participants

The current review will consider any registered or enrolled nurses or midwives regulated by a nursing or midwifery board or recognized health practitioner regulation agency (or their international equivalent).27 They can be of any sex, aged 18 years and over, and of any ethnicity who have sustained an MSD of any severity at their workplace and have been involved in a RTW program.

The current review will only focus on work-related MSDs as RTW programs are not available to support non-work-related injuries.10

Musculoskeletal disorder will be defined as “injuries or disorders of the muscles, tendons, nerves, ligaments, joints, and cartilage, expanding to include disorders of nerves, tendons, muscles supporting structures of the upper and lower limbs, neck, and lower back”.1(p.16) Nurses and midwives who have had a previous MSD, whether or not work-related, will be excluded.

The current review will also include RTW coordinators who are involved in returning injured nurses or midwives to their workplace. Notably, the title of RTW coordinator varies between states in Australia, and in the international context, RTW coordinators are also known as disability managers, case managers, disability prevention specialists and disability supervisors.13 Due to the use of different titles for “RTW coordinators,” anyone who manages programs assisting the return of injured nurses or midwives to their workplace will be considered.

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Phenomena of interest

The current systematic review will consider both the positive and negative experiences and expectations of nurses or midwives with work-related MSDs and RTW coordinators involved in RTW programs.

Return-to-work programs can be of any duration, consist of multiple different interventions (e.g. graduated work and modified duties) and can be delivered by any type of professionals (e.g. doctors, physiotherapists, occupational therapists, psychologists, massage technicians, etc.).

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The current systematic review will consider nurses or midwives with work-related MSDs and/or RTW coordinators from any healthcare setting (e.g. primary care, aged care, acute care, etc.) in any country.

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Types of studies

The current review will consider studies that focus on qualitative data including, but not limited to, designs such as phenomenology, grounded theory, ethnography, action research and gender research.

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Search strategy

The search strategy aims to find both published and unpublished studies. A three-step search strategy will be utilized in this review. An initial limited search of CINAHL, MEDLINE and Embase will be undertaken followed by analysis of the text words contained in the title and abstract, and of the index terms used to describe the article.

A second search using all identified keywords and index terms will then be undertaken across all included databases. Third, the reference list of all identified reports and articles will be searched for additional studies.

Studies published in English will be considered for inclusion in this review.

The date range of the search will be 1987 to the present as RTW practice was introduced by many worker's compensation boards in North America and Europe throughout the 1990s17 and following the Workers Compensation Act 1987 in Australia.16

The databases to be searched include CINAHL, Embase, PubMed and PsycInfo.

The search for unpublished studies will include Scopus, ProQuest Dissertations and Theses and Networked Digital Library of Theses and Dissertations.

Initial keywords to be used will be return to work, back to work, job re-entry, rehabilitation, nurse, midwife, injury, trauma, experience, expectation and qualitative.

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Assessment of methodological quality

Papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using the standardized critical appraisal instrument from the Joanna Briggs Institute Qualitative Assessment and Review Instrument (JBI-QARI) (Appendix I). Any disagreements that arise between the reviewers will be resolved through discussion or with a third reviewer.

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Data extraction

Data will be extracted from individual studies independently using the standardized data extraction tool from JBI-QARI (Appendix II). The extracted data will include specific details about the phenomenon of interest, populations, study methods and outcomes of significance to the review question and specific objectives.

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Data synthesis

Qualitative research findings will, where possible, be synthesized using a meta-aggregative approach. The Joanna Briggs Institute Qualitative Assessment and Review Instrument will be used to assist in this process. Meta-aggregation involves the aggregation or synthesis of findings to generate a set of statements that represent that aggregation. Meta-aggregation involves a three-step process. First, findings and their accompanying illustration will be extracted and rated according to their level of credibility (Level 1 findings). Second, findings will be categorized on the basis of similarity in meaning (Level 2 findings). These categories will then be subjected to a meta-synthesis to produce a single comprehensive set of synthesized findings (Level 3 findings) that can be used as a basis for evidence-based practice.

Where textual pooling is not possible, the findings will be presented in narrative form.

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Appendix I: Appraisal instrument

QARI appraisal instrument



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Appendix II: Data extraction instrument

QARI data extraction instrument





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Expectation; experience; midwife; nurse; rehabilitation; return to work

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