Perceived health, musculoskeletal disorders, work conditions and safety climate in relation to patient handling and movement − a multicentre cross-sectional study at healthcare workplaces

TL;DR

Healthcare workers face significant physical and organizational challenges related to patient handling, with high rates of musculoskeletal disorders and a need for better safety policies and support.

Contribution

The study compares healthcare workers' health and work conditions in hospitals and nursing homes, identifying key factors affecting safety climate and desired improvements.

Findings

79% of healthcare workers reported musculoskeletal symptoms in the past week, with nursing home workers experiencing more pain in extremities.

Hospital workers showed lower adherence to safety policies and less systematic risk assessment compared to nursing home workers.

Managerial support and clear guidelines were strongly associated with a better perceived safety climate.

Abstract

A safe healthcare work environment is essential to promote patient safety and healthcare workers’ (HCWs) well-being. Nevertheless, musculoskeletal disorders (MSDs) remain highly prevalent, particularly in relation to patient handling and movement (PHM). This study aims to describe and compare HCWs health, MSDs, working conditions, and safety climate in relation to PHM in hospital care units and nursing homes, as well as to identify desired workplace improvements.

This multicentre cross-sectional study was based on data collected in 2023 as part of a prospective cluster-randomized trial conducted in Sweden. In total, 1,214 HCWs in 17 hospital care units and 27 nursing homes completed a questionnaire assessing health, PHM routines, organizational conditions, and safety climate using the NOSACQ-50 instrument. Factor analyses of PHM and work environment variables informed mixed linear regression models, evaluating associations with perceived safety climate. Qualitative content analysis was performed on open-ended responses regarding desired workplace improvements.

MSDs were highly prevalent, with 79% of HCWs reporting symptoms in the past week. Nursing home HCWs experienced more pain sites, particularly in extremities. Compared to nursing home HCWs, hospital care HCWs more frequently disagreed that PHM activities were guided by clear policies, written guidelines, established routines, or regular training (p < 0.001). Hospital HCWs demonstrated lower adherence to safety policies and less systematic risk assessment. Despite these challenges, the overall perceived safety climate was moderately positive, with NOSACQ-50 mean scores ranging from 3.1 to 3.6. Over 40% of HCWs reported significant physical work environment issues, including heavy lifting, repetitive movements, uncomfortable positions, and high work pace. Regression analyses revealed that organizational support, clear guidelines, ergonomic and psychosocial work factors, and especially managerial support (p < 0.001), were strongly associated with higher perceived safety climate. Qualitative data mostly underscored needs for improved staffing, education, structured routines, and better access to assistive equipment, particularly ceiling lifts.

Substantial physical and organizational challenges related to PHM were reported by HCWs across both care contexts. The findings suggest that interventions emphasizing leadership engagement, a systematic approach to training, and tailored solutions are essential to strengthen the safety climate and reduce HCWs’ health risks.

NCT05276180 Registration date 02112022.

The online version contains supplementary material available at 10.1186/s12891-025-09330-3.

Full text

Background

Creating a safe care and work environment for patients and healthcare workers (HCWs) relies on effective systematic management of both patient safety and organizational safety. When organizations hold collective beliefs, values, and behaviours prioritizing and supporting safety, a strong safety culture can be built, contributing to safety for both patients and HCWs [1, 2]. However, there is still a lack of safety for patients and HCWs, with numerous risk factors for potential incidents and injuries [3, 4]. There is a call for support of the healthcare workforce to provide safe care for patients, as there is no patient safety without HCW safety [5, 6]. The primary causes of work-related musculoskeletal disorders (WMSDs) among HCWs stem from high physical and mental workload, staffing shortages, and limited influence over work conditions, as well as lack of support from colleagues and lack of availability of assistive devices for safe patient handling and movement (PHM) [7, 8]. WMSDs among HCWs are linked to several factors, including years of experience in direct patient care, management strategies promoting early mobilization, low job satisfaction, and a lower perception that management cares about safety [9]. WMSDs may occur during repetitive work tasks or in awkward postures such as when performing PHM [3, 8, 10]. Notably, WMSDs arising from PHM rank among the most prevalent injuries. These injuries predominantly affect the lumbar spine, neck, and shoulders, and are most frequent among nurses and assistant nurses [9, 11, 12].

Recent reviews of epidemiological studies report a high annual prevalence rate of WMSDs among nurses, with rates up to 77.2% [12]. However, none of the studies included in the reviews were conducted in a Scandinavian country where HCWs are employed within regional healthcare services and municipalities, such as in hospital care units and nursing homes. In Sweden, healthcare is provided by 21 regions and 290 municipalities, with different geographical and organizational prerequisites [13]. In order to prevent WMSDs among HCWs and promote safety in relation to PHM routines, risks assessments and appropriate multifactorial workplace interventions are suggested [8, 14]. Equipment availability, ceiling lift availability, supervisor encouragement, and annual training increase HCWs’ use of equipment for PHM [9, 14, 15]. Perceptions of organizational safety practice are important as high perceptions are associated with lower physical workload and WMSDs [16]. Moreover, ensuring the safety of PHM requires that both managers and HCWs prioritize and adhere to safety practices. Several standards and guidelines on safe PHM support the importance of establishing a culture of safety and implementing practices for risk assessment, training and maintaining competence [17, 18]. In a recent study, the Swedish version of the risk assessment instrument TilThermometer was found feasible for assessing risks of physical exposure among HCWs in relation to PHM [19]. However, it is unclear if practices for risk assessment and interventions to promote safe PHM are used and prioritized within Swedish hospital care units and nursing homes. Despite many challenges with WMSDs among HCWs, research focusing on HCWs’ perceptions of safe PHM in healthcare workplaces remains scarce.

The aim of the present study was to describe and compare HCWs’ health, MSDs, working conditions and occupational safety climate in relation to PHM in hospital care units and nursing homes, and to examine factors associated with levels of safety climate. A further aim was to identify areas of work environment improvements in relation to PHM.

Methods

Study design

This multicentre cross-sectional study is part of a cluster-randomized controlled trial evaluating intervention strategies for safe PHM in the healthcare sector. Detailed information about the research project is provided in the published study protocol [20]. The baseline data of the project were used for the present study. Ethics approval was received from the Swedish National Ethical Board (Dnr 2021–00578). This study adheres to the CONSORT guidelines and includes a completed CONSORT checklist as an additional file (Supplementary Material 1).

Healthcare setting and study sample

The inclusion criteria for this study were HCWs in the healthcare sector, including hospital care units (regional healthcare sector) and nursing homes (municipal healthcare sector). The hospital care units were inpatient care units with a minimum of 15 HCWs employed at the unit. The nursing homes were units for older adults with a minimum of 15 HCWs employed at the unit. The care units were located in different parts of Sweden in larger, mid-sized and small cities. The exclusion criteria for the study were care units providing outpatient home nursing, paediatric care, parts of emergency care and psychiatric care.

In Sweden, healthcare services are primarily administered by regional and local authorities (municipalities). Care is delivered within hospital settings as well as in municipal care environments, each characterized by distinct organizational structures, differences in the demographics of care recipients, and varying levels of available resources and support. A major distinction between the two settings is that hospital care patients typically have shorter stays focused on acute care, whereas elderly individuals in municipal care often reside long-term in nursing homes. Including both types of care units − hospital care units and nursing homes − and comparing them with regard to safety climate and the health status of HCWs may provide valuable insights.

Recruitment and data collection

Information about the study and recruitment of workplaces in hospital care units and nursing homes took place between 2022-10-01 and 2023-01-15. This was done through contact people such as managers and HR representatives, as well as via various communication channels, including union representatives, social media, and newsletters. Care units who expressed interest received detailed information about the study and its procedures from the research team. Managers shared the information with HCWs through emails and workplace meetings. Before officially joining the study, the manager at each care unit signed an informed written consent.

All participants received oral information about the study from their managers and written information from the research group. HCWs gave their informed consent prior to answering the questionnaire. The questionnaire was digitally distributed to HCWs at participating units between February and March 2023. Reminders were sent out by email once a week. A description of the questions and items included in the questionnaire is provided below.

Questionnaire

Contextual factors were collected from each participating care unit at baseline concerning type of care unit and staffing levels. The questionnaire answered by the HCWs contained questions about individual factors, health and musculoskeletal and work-related disorders, work ability, work performance and sick leave, participation in patient handling and movement (PHM), work conditions, safety climate, and open questions concerning HCWs’ suggestions on work environment improvements.

Individual characteristics

Participants answered questions on their age, sex, profession, and years at their current workplace.

Health, musculoskeletal and work-related disorders

General self-reported health was obtained by the question: “In general, would you say your health is…?”, with a five-point ordinal rating scale ranging between excellent and poor [21]. Other questions concerned musculoskeletal pain and symptoms from the neck, shoulders, elbows, wrists/hands, back, and lower extremities. The participants were asked about the prevalence of pain in these locations during the previous 12 months, and in the previous seven days [22]. They reported if they had problems related to mental or physical exposure at work: “Do you experience problems related to the load and work tasks that you perform in your current job?” with response options “yes” or “no”. If yes, a list was presented where one or more alternatives could be specified: neck, shoulders, elbows, wrists/hands, thoracic spine, lumbar spine, hips, knees, ankles/feet, headache, stress-related problems, depression, and other with an open answer option.

Work ability, work performance, presenteeism and sick leave

HCWs responded to the single item “current work ability compared with life-time best” on an 11-point ordinal rating scale from 0 to 10 [23]. The work ability of the HCWs was also assessed in relation to physical and mental demands at work based on the work ability index using a 5-point Likert scale, ranging from 1 “Very poor” to 5 “Very good” (WAI) [24]. Furthermore, HCWs were asked whether they had experienced any work environment problems affecting health and work performance and sickness presence (presenteeism) in the previous seven days [25, 26]. Participants were asked whether their illness or injury constituted a hindrance in their current work. Seven response options were available to capture the extent of perceived work limitations, ranging from no hindrance to complete inability to work. In previous studies, self-reported sickness absence has been shown to have acceptable reliability [27]. One question focused on sickness absence: “How many days have you been absent from work due to illness or injury in the past year?” with the rating alternatives: no days, 1–7 days; 8–12 days; 25–99 days; 100–365 days.

Patient handling and movement (PHM)

The frequency of PHM was evaluated based on questions from a previous study [7]: “How many patients do you PHM per day on a regular working day?” with the rating alternatives: [1] none; [2] one day a week; [3] 2–3 days per week; [4] 4 days per day; [5] every working day; [6] 1–5 times per day; [7] 6–10 times per day; [8] 11–20 times per day; [12] 21 or more times per day. The same scale was also used to evaluate (1) how often a transfer is performed together with a colleague, and (2) how often transfer was performed without using the aids needed to perform it in a safe way. Patient mobility independence was assessed by asking about the.

proportion of patients able to do transfers independently and without using aids/equipment during the past week, with five statements rating from “No patients” to “All patients”. The Borg-CR 10 scale was used [28, 29] specifically for reporting work strain in relation to PHM and participants reported how often PHM was performed each day. Furthermore, 14 research questions were used to assess the safety climate in relation to PHM, previously published in a Swedish guideline [17]. These questions involved the dimensions of using equipment, other aspects of safety, performing risk assessment, and collaboration between caregivers and patients. Responses were rated on a 4-point ordinal scale ranging from 1 (Strongly disagree) to 4 (Strongly agree) (Supplementary Material 2).

Work conditions

Part of the Structured Multidisciplinary Work Environment Survey (SMET) [30] was used. It contains questions about physically, environmentally and psychosocially demanding work tasks. The answers from the SMET questionnaire are trichotomized [1–10] and categorized as 1–3 = low degree of problems, 4–7 = some degree of problems, and 8–10 = high degree of problems. The questionnaire also included a question on work conditions regarding change of workload over time, where responses were rated on a 3-point ordinal scale (1 = decreased; 2 = unchanged; 3 = increased).

Safety climate

The safety climate was measured using NOSACQ-50, a questionnaire that has been validated in various contexts [31]. This questionnaire comprises 50 items across seven safety climate dimensions in the workplace: (1) management safety priority, commitment and competence; (2) management safety empowerment; (3) management safety justice; (4) workers’ safety commitment; (5) workers’ safety priority and risk non-acceptance; (6) safety communication, learning and trust in co-workers’ safety competence; and (7) trust in the efficacy of safety system. The questionnaire is scored on a 4-point ordinal rating scale, ranging from 1 (“strongly disagree”) to 4 (“strongly agree”). The score for each dimension consists of the mean value of the included items, where a score greater than 3.30 on each dimension indicates a good level for safety climate and the need for continuing safety development. A total score for NOSACQ was calculated as the mean of NOSACQ dimensions 1 to 7. The total score has been used and presented in previous research [32].

HCWs’ suggestion for work environment improvements

HCWs responded to three open-ended questions designed to gather suggestions for workplace improvements: (1) “Do you have suggestions on how your work environment and aspects of safety can be improved at your workplace?”; (2) “Do you have suggestions on work methods, equipment, or assistive devices that could facilitate tasks related to patient transfers?”; and (3) “Do you have other suggestions regarding patient handling and movement?”.

Statistical analysis

Descriptive data were presented with mean and SD, median and range, or counts and percentages. The independent t-test was used for comparisons of continuous variables between groups. Mann-Whitney U-test were used for comparison between groups of variables on an ordinal scale. Differences in proportions between groups were examined with chi-squared tests or Fisher’s exact test. Comparative analysis was made in relation to safety climate, working conditions, and type of organization/care unit.

The NOSACQ-50 total score was used as the primary outcome (dependent variable) of the regression analyses. A mixed linear regression model was used to account for the fact that individuals are nested within healthcare units. In a first step, a factor analysis was performed to derive simplified dimensions of measured aspects of Safety PHM and SMET, respectively. The extraction method was principal component analysis, and an orthogonal rotation was performed with varimax and Kaiser normalization [33]. Factors not considered relevant to the research question were not included in the regression analysis. For each identified relevant dimension, the factor scores were computed for each respondent and were used as independent variables in subsequent regression analysis. Taking into account that individuals are nested within healthcare units, a mixed linear regression was used to examine associations between NOSACQ total and the derived dimensions of Safety PHM and SMET (occupational characteristics), age (individual characteristic), and manager support (SMET28 item 3). A level of 5% was considered to be statistically significant. The quantitative data were analysed using IBM SPSS version 29 and Stata 18.

Responses to the three open-ended questions on suggestions for work environmental improvements were systematically analysed with a summative and manifest approach to qualitative content analysis [34].This implies analyzing for the appearance of a particular word or content in textual material, a quantification to explore usage instead of inferring meaning. Initially, all responses were carefully read to identify recurring areas for improvement. First, categories were developed inductively, each representing a distinct aspect of workplace improvement in relation to PHM, such as working routines, safety practices, and equipment suggestions. Thereafter text contents were systematically coded into the categories, followed by a quantification of the distribution of responses across the categories. CW developed the categories, and CW together with PE coded the data, which were subsequently discussed and agreed upon with ENS and JS.

Results

Individual characteristics

In total, 1,214 HCWs answered the baseline questionnaire, of which 510 worked at 17 hospital care units, and 704 worked at 27 nursing homes; see Table 1. Participants working at hospital care units had a lower mean (SD) age (40.7 (12.7)) than those working at nursing homes (47.9 (11.9)). Most participants were women, with a higher proportion of men working at hospital care units (13.7%, n = 70) than at nursing homes (8.4%, n = 59), p = 0.005. Most participants were either assistant nurses (69.6%) or nurses (17.8%), with a lower proportion of assistant nurses and a higher proportion of nurses working at hospital care units compared to nursing homes (50.2% versus 83.7%, and 39.0% versus 2.4%, respectively). Participants from hospital care units more often worked 76% to full-time compared to participants from nursing homes (93.4% versus 85.1%, respectively, p < 0.001). Participants from hospital care units had more years at their current workplace than those working at nursing homes (p < 0.001).Table 1. Individual characteristics, health, musculoskeletal and work-related disorders of health care workers (HCWs). Comparison between hospital care and nursing home HCWsItems/questionTotal all HCWsn = 1 214Hospital Care units HCWsn = 510Nursing homes HCWs,n = 704P-valueCare units441727Age in years, mean (SD)44.9(12.8)40.7(12.7)47.9(11.9)< 0.001^t^Range20–6820–7020–70Sex,** n (%)0.005^F^Male129(10.6)70(13.7)59(8.4)Female1081(89.0)439(86.1)642(91.2)Prefer not to say4(0.3)1(0.2)3(0.4)Profession, n (%)< 0.001Assistant nurse845(69.6)256(50.2)589(83.7)Nurse216(17.8)199(39.0)17(2.4)Care assistant62(5.1)1(0.2)61(8.7)Occupational-/Physical therapist58(4.8)34(6.7)24(3.4)Other33(2.7)20(3.9)13(1.8)Years at workplace,** n (%)< 0.001< 2 years316(26.0)178(34.9)138(19.6)< 5 years259(21.3)125(24.5)134(19.0)5–10 years268(22.1)84(16.5)184(26.1)>10 years371(30.6)123(24.1)248(35.2)General health**< 0.001**^M^Excellent90(7.4)51(10.0)39(5.5)Very good363(29.9)181(35.5)182(25.9)Good533(43.9)197(38.6)336(47.7)Fair209(17.2)76(14.9)133(18.9)Bad19(1.6)5(1.0)14(2.0)During the past 12 months,** have you had…….Musculoskeletal pain, yes1138(93.7)475(93.1)663(94.2)0.461number of locations, mean (SD)4.4(2.4)4.1(2.3)4.6(2.5)< 0.001**^M^Neck pain853(70.3)364(71.4)489(69.5)0.472Shoulder, elbow and/or wrist/hand pain947(78.0)378(74.1)569(80.8)0.005Lumbar spine pain901(74.2)372(72.9)529(75.1)0.387Hip, knee and/or ankle/foot pain787(64.8)311(61.0)476(67.6)**0.017During the past 7 days,** have you had…….Musculoskeletal pain, yes975(78.8)396(77.6)561(79.7)0.390number of locations, mean (SD)2.7(2.3)2.4(2.1)3.0(2.5)< 0.001**^M^Neck pain496(40.9)203(39.8)293(41.6)0.525Shoulder, elbow and/or wrist/hand pain656(54.0)248(48.6)408(58.0)0.001Lumbar spine pain575(47.4)228(44.7)347(49.3)0.114Hip, knee and/or ankle/foot pain570(47.0)207(40.6)363(51.6)**< 0.001Mental and/or physical work related problems in current workwork-related problems, yes925(76.2)365(71.6)560(79.5)0.001number of work-related problems2.1(1.9)1.7(1.6)2.4(2.1)< 0.001^M^Neck pain419(34.5)170(33.3)249(35.4)0.461Shoulder, elbow and/or wrist/hand pain624(51.4)211(41.4)413(58.7)< 0.001Low back pain493(40.6)192(37.6)301(42.8)0.074Hip, knee and/or ankle/foot pain410(33.8)125(24.5)285(40.5)< 0.001Headache313(25.8)140(27.5)173(24.6)0.258Stress-related problems347(28.6)138(27.1)209(29.7)0.317Depression105(8.6)53(10.4)52(7.4)0.066Other health problems61(5.0)24(4.7)37(5.3)0.665 The p-values show the difference between hospital care and nursing home health care workers (HCWs). The p-values represent Chi-square test p-values, unless stated otherwise. ^t^ independent sample t-test p-value; ^F^ Fisher’s exact test; ^M^ Mann-Whitney U test p-value; bold figures represent p-values < 0.05

General health, musculoskeletal and work-related disorders

About 80% of all participants reported excellent to good general health, see Table 1. Almost 94% of all participants reported having had musculoskeletal pain during the past 12 months, with participants from hospital care units reporting pain at a lower mean (SD) number of locations than participants from nursing homes (4.1 (2.3) versus 4.6 (2.5), respectively). Pain located in the neck, the lumbar spine, and in the upper or lower extremities was common. There were no significant differences regarding neck or lumbar spine pain during the past 12 months between the groups, while participants from hospital care units less often had pain in the upper and lower extremities than participants from nursing homes (74.1% and 61% versus 80.8% and 67.6%, respectively).

Almost 80% of all participants reported musculoskeletal pain during the past seven days, with participants from hospital care units reporting pain at a lower mean (SD) number of locations than participants from nursing homes (2.4 (2.1) versus 3.0 (2.5), respectively, p < 0.001). Again, pain located in the neck, the lumbar spine, and in the upper or lower extremities was common. There were no significant differences regarding neck or lumbar spine pain during the past seven days between the groups, while participants from hospital care units less often had pain in the upper and lower extremities than participants from nursing homes (48.6% and 40.6% versus 58% and 51.6%, respectively, p < 0.001).

The percentage and number of problems related to physical or mental workload was lower in participants working in hospital care units than those working in nursing homes (71.6% and 1.6 versus 79.5% and 2.1, respectively, p ≤ 0.001). Besides musculoskeletal problems, headache (25.8%), stress related problems (28.6%) and depression (8.6%) were problems related to participants’ mental and/or physical workload.

Work ability, work performance and sick leave

About three-quarters of the participants (76.3%) reported their current work ability to be very good or good in relation to the physical demands, and 73.1% reported their current work ability to be excellent or good in relation to the mental demands of their work, see Table 2. Participants working at hospital care units more often reported that they did not have an illness or injury or that these were an obstacle in their current work compared to participants from nursing homes (66.1% versus 41.3%, p = 0.003–0.006). Fewer participants working at hospital care units than those working at nursing homes reported they could do their work but get symptoms (35.9% versus 45.3%, respectively). In total 28.3% of participants reported that they had been on sick leave for eight days or more during the past 12 months. Almost half of the participants (41.4%) had experienced health problems during the past seven days but still chose to go to work. There were no significant differences in sick leave or experiencing health problems but still going to work between participants at hospital care units or nursing homes.Table 2. Work ability, work performance and sick leave. Comparison between hospital care and nursing home health care workers (HCWs)Items/questionTotal all HCWsn = 1 214Hospital Care units HCWsn = 510Nursing homes HCWsn = 704P-valuen(%)n(%)n(%)Work abilityWork ability now compared to highest ever work ability, 0–108.6(1.8)8.7(1.7)8.4(1.8)0.018^M^How do you assess your current work ability in relation to the physical demands of your work?< 0.001^M^Very good296(24.4)161(31.6)135(19.2)Good630(51.9)255(50.0)375(53.3)Moderate245(20.2)80(15.7)165(23.4)Bad or very bad43(3.5)14(2.7)29(4.1)How do you assess your current ability to work in relation to the mental demands your work makes?0.013Very good279(23.0)134(26.3)145(20.6)Good608(50.1)261(51.2)347(49.3)Moderate269(22.2)96(18.8)173(24.6)Bad or very bad58(4.8)19(3.7)39(5.5)**Fit for work 1–7Is your illness or injury an obstacle in your current work?There are no obstacles437(36.0)208(40.8)229(32.5)0.003I have no illnesses or injuries261(21.5)129(25.3)132(18.8)0.006I can do my job, but get symptoms502(41.4)183(35.9)319(45.3)< 0.001I sometimes have to reduce the pace of work or change the way I work148(12.2)50(9.8)98(13.9)0.030I often have to reduce the pace of work or change the way I work35(2.9)9(1.8)26(3.7)0.047Due to my illness or injury, I can only work part-time51(4.2)19(3.7)32(4.5)0.482In my own opinion, I am completely unable to work4(0.3)0(0.0)4(0.6)0.088Work environment and sickness absence/presenceHow many days have you been away from work due to illness or injury (care, treatment or examination) in the past year?0.071^M^None438(36.1)195(38.2)243(34.5)1–7 days433(35.7)183(35.9)250(35.5)8–24 days246(20.3)99(19.4)147(20.9)25–99 days79(6.5)29(5.7)50(7.1)100–365 days18(1.5)4(0.8)14(2.0)During the past seven days, have you experienced problems (physical, mental, social) in your work environment? (yes)479(39.5)200(39.2)279(39.6)0.884Have you experienced health problems in the past seven days but still chose to go to work? (yes)503(41.4)195(38.2)308(43.8)0.054MeanSDMeanSDMeanSDDuring the past seven days, to what extent did work environment-related problems affect your work performance ^a^3.6(2.6)3.7(2.5)3.6(2.6)0.431^M^During the past seven days, to what extent did health problems affect your work performance ^b^3.1(2.5)3.0(2.4)3.3(2.6)0.069^M^^a^ Effect on work performance by work environment related problems score 0 “work environment problems have not affected my work performance” to 10 “work environment problems completely prevented me from working”^b^ Effect on work performance by health problems score 0 “health problems have not affected my work performance” to 10 “health problems completely prevented me from working” The p-values show the difference between hospital care and nursing home health care workers (HCWs). The p-values represent Chi-square test p-values, unless stated otherwise. ^M^ Mann-Whitney U test p-value; bold figures represent p-values < 0.05

Patient handling and movement (PHM)

Many participants (82.2%) participated at least every working day in PHM, while 25.9% did so between six to more than 20 times daily; see Table 3. Participants working at hospital care units less often reported that they carried out patient transfers with a colleague every working day than participants from nursing homes (67.6% versus 80.8%, respectively, p < 0.001). In total, 78% of participants carried out PHM without using aids/equipment up to four days per week, while 22% did so at least every working day. Some participants (3.6%) carried out PHM without using aids/equipment six to more than 20 times per day.Table 3. Work task and performance in patient handling and movement (PHM). Comparison between hospital care and nursing home health care workers (HCWs)Items/questionTotal all HCWsn = 1 214Hospital Care units HCWsn = 510Nursing homes HCWsn = 704P-valuen*(%)n(%)n(%)PHMHow often do you participate in patient transfers?0.044^M^Never to 1 day per week86(7.1)46(9.0)40(5.7)2–4 days per week130(10.7)72(14.1)58(8.3)Every working day539(44.5)194(38.0)345(49.1)1–5 times daily143(11.8)75(14.7)68(9.7)6–10 times daily152(12.5)67(13.1)85(12.1)11–20 times daily116(9.6)41(8.0)75(10.7)>20 times daily46(3.8)15(2.9)31(4.4)How often do you carry out patient transfers with a colleague?< 0.001**^M^Never to 1 day per week126(10.4)57(11.2)69(9.8)2–4 days per week174(14.4)108(21.2)66(9.4)Every working day543(44.8)196(38.5)347(49.4)1–5 times daily141(11.6)60(11.8)81(11.5)6–10 times daily138(11.4)61(12.0)77(11.0)11–20 times daily67(5.5)24(4.7)43(6.1)>20 times daily22(1.8)3(0.6)19(2.7)How often do you carry out patient transfers without using aids/equipment?0.559^M^Never to 1 day per week866(71.5)355(69.7)511(72.8)2–4 days per week79(6.5)54(10.6)25(3.6)Every working day182(15.0)63(12.4)119(17.0)1–5 times daily41(3.4)21(4.1)20(2.8)6–10 times daily25(2.1)10(2.0)15(2.1)11–20 times daily13(1.1)5(1.0)8(1.1)>20 times daily50.4)1(0.2)4(0.6)Proportion of patients able to do transfers independently and without using aids/equipment during past week**< 0.001**^M^No patients/care recipient133(11.0)40(7.9)93(13.2)Some patients/care recipients, about one quarter.623(51.4)242(47.5)381(54.3)Half of the patients/care recipients267(22.0)140(27.5)127(18.1)Many patients/care recipients (about three quarters)156(12.9)79(15.5)77(11.0)All patients/care recipients.32(2.6)8(1.6)24(3.4)Work strainMeanSDMeanSDMeanSDHow do you estimate the physical effort you generally experience during patient transfers ^a^6.1(2.3)5.9(2.1)6.2(2.4)0.063^M^^a^ Score 0 “none” to 10 “extremely large”* The p-values show the difference between hospital care and nursing homes health care workers (HCW). ^M^ Mann-Whitney U test p-value; bold figures represent p-values < 0.05

Safety in relation to PHM

Most participants agreed or strongly agreed that they made an effort together to carry out safe PHM (94.6%) and had access to work equipment and aids (97.1%), but only 74.9% reported that there is a fixed ceiling lift where needed; see Table 4. Participants working at hospital care units strongly disagreed or disagreed that their work was based on a work environment policy, a written guideline, established routines or some specific method more often than participants from nursing homes (p < 0.001). Participants working at hospital care units more often strongly disagreed or disagreed that before carrying out PHM they assessed the patient’s health and function, the ability to move themselves, and the need for more healthcare workers to do the transfer, than participants from nursing homes (p < 0.001). Furthermore, participants working at hospital care units more often strongly disagreed or disagreed that they regularly conducted training in PHM and discussed how to prevent work-related injuries during PHM, than participants from nursing homes (p < 0.001).Table 4. Safety in relation to patient handling and movement (PHM). Comparison between hospital care and nursing home health care workers (HCWs)Total all HCWsn = 1 214Hospital Care units HCWsn = 510Nursing homes HCWsn = 704P-valuen%n%n%**PHM1. We who work here make an effort together to carry out safe PHM0.002^M^Strongly disagree14(1.2)3(0.6)11(1.6)Disagree52(4.3)29(5.7)23(3.3)Agree516(42.5)239(46.9)277(39.3)Strongly agree632(52.1)239(46.9)393(55.8)2. At our workplace,** we have access to work equipment and aids that we can use when working with PHM0.003^M^Strongly disagree6(0.5)1(0.2)5(0.7)Disagree29(2.4)13(2.5)16(2.3)Agree351(28.9)173(33.9)178(25.3)Strongly agree827(68.2)323(63.3)504(71.7)3. At our workplace there is a fixed ceiling lift where needed0.067^M^Strongly disagree223(18.4)39(7.6)184(26.2)Disagree82(6.8)55(10.8)27(3.8)Agree263(21.7)154(30.2)109(15.5)Strongly agree645(53.2)262(51.4)383(54.5)**4. We who work here take joint responsibility for the use of work equipment and aids when working with PHM0.001^M^Strongly disagree10(0.8)5(1.0)5(0.7)Disagree53(4.4)29(5.7)24(3.4)Agree389(32.1)184(36.1)205(29.2)Strongly agree761(62.7)292(57.3)469(66.7)5. At our workplace,** we work based on a work environment policy***< 0.001**^M^Strongly disagree35(2.9)17(3.3)18(2.6)Disagree89(7.3)47(9.2)42(6.0)Agree464(38.3)223(43.7)241(34.3)Strongly agree624(51.5)223(43.7)401(57.1)6. At our workplace,** we work based on a written guideline for the PHM****< 0.001**^M^Strongly disagree73(6.0)53(10.4)20(2.8)Disagree172(14.2)121(23.7)51(7.3)Agree415(34.2)204(40.0)211(30.1)Strongly agree552(45.5)132(25.9)420(59.8)7. At our workplace,** we work based on an established routine for how to carry out risk assessments when working with PHM****< 0.001**^M^Strongly disagree99(8.2)66(12.9)33(4.7)Disagree186(15.3)110(21.6)76(10.8)Agree415(34.2)198(38.8)217(30.9)Strongly agree512(42.2)136(26.7)376(53.6)8. Before we do a PHM we carry out a risk assessment according to some specific methodStrongly disagree206(17.0)131(25.7)75(10.7)Disagree236(19.5)141(27.6)95(13.5)Agree376(31.0)139(27.3)237(33.8)Strongly agree394(32.5)99(19.4)295(42.0)9. Before we carry out PHM,** we assess the health and functional capacity of the patient/care recipient****< 0.001**^M^Strongly disagree18(1.5)7(1.4)11(1.6)Disagree55(4.5)27(5.3)28(4.0)Agree332(27.4)174(34.1)158(22.5)Strongly agree807(66.6)302(59.2)505(71.9)10. Before we do a PHM,** we assess the patient/care recipient’s risk of falling****< 0.001**^M^Strongly disagree15(1.2)3(0.6)12(1.7)Disagree45(3.7)26(5.1)19(2.7)Agree300(24.8)166(32.5)134(19.1)Strongly agree852(70.3)315(61.8)537(76.5)11. Before we carry out PHM,** we assess the patient’s/care recipient’s ability to move themselve****< 0.001**^M^Strongly disagree13(1.1)3(0.6)10(1.4)Disagree49(4.0)18(3.5)31(4.4)Agree322(26.6)175(34.3)147(20.9)Strongly agree828(68.3)314(61.6)514(73.2)12. Before we carry out PHM,** we assess whether we need more healthcare workers to be able to transfer the patient0.110^M^Strongly disagree15(1.2)2(0.4)13(1.9)Disagree30(2.5)10(2.0)20(2.8)Agree288(23.8)143(28.0)145(20.7)Strongly agree879(72.5)355(69.6)524(74.6)13. At our workplace, we regularly conduct training in the area of PHM and transfer techniques****< 0.001**^M^Strongly disagree190(15.7)109(21.4)81(11.5)Disagree285(23.5)146(28.6)139(19.8)Agree345(28.5)138(27.1)207(29.5)Strongly agree392(32.3)117(22.9)275(39.2)14. At our workplace,** we regularly discuss how we can prevent work-related injuries during PHM****< 0.001**^M^Strongly disagree140(11.6)82(16.1)58(8.3)Disagree293(24.2)165(32.4)128(18.2)Agree417(34.4)173(33.9)244(34.8)Strongly agree362(29.9)90(17.6)272(38.7)* The p-values show the difference between hospital care and nursing homes health care workers(HCW), bold figures represent p-values < 0.05. ^M^ Mann-Whitney U test p-value; bold figures represent p-values < 0.05

Work conditions

About 60% of participants reported that the workload had increased since they started working at their current workplace; see Table 5. A considerable number of participants experienced a high degree of problems in their work associated with the physical work environment; these included: heavy lifting n = 535 (44.1%), repetitive movements n = 401 (33%), unilateral or fixed working positions n = 299 (24.6%), uncomfortable working positions n = 454 (37.4%), a high work-pace n = 438 (36.1%), and narrow spaces n = 317 (26.1%); see Table 5. The item responsibilities, rights and/or expectations had the lowest number (%) of participants experiencing a high degree of problems, n = 116 (9.6%), and the item anxiety about not having time to complete your work had the highest number n = 241 (19.9%).Table 5. Workload and work conditions (SMET). Comparison between hospital care and nursing home health care workers (HCWs)Items/questionTotal all HCWsn = 1 214Hospital Care units HCWsn = 510Nursing homes HCWsn = 704P-valuen%n%n%**How have your work conditions regarding workload changed at this workplace since you started?**0.317Decreased74(6.1)28(5.5)46(6.5)Unchanged438(36.1)196(38.4)242(34.4)Increased701(57.8)286(56.1)415(59.0)**SMETPhysical work environment Do you, in your work, experience any problems associated with.Physical work environmentHeavy lifting?0.373low degree of problems221(18.2)95(18.6)126(17.9)some degree of problems458(37.7)202(39.6)256(36.4)high degree of problems535(44.1)213(41.8)322(45.7)Repetitive movements?0.002low degree of problems325(26.8)154(30.2)171(24.3)some degree of problems488(40.2)215(42.2)273(38.8)high degree of problems401(33.0)141(27.6)260(36.9)Unilateral or fixed working positions?0.192low degree of problems404(33.3)180(35.3)224(31.8)some degree of problems511(42.1)217(42.5)294(41.8)high degree of problems299(24.6)113(22.2)186(26.4)Uncomfortable working positions?0.501low degree of problems282(23.2)127(24.9)155(22.0)some degree of problems478(39.4)196(38.4)282(40.1)high degree of problems454(37.4)187(36.7)267(37.9)A high work-pace?0.028low degree of problems292(24.1)104(20.4)188(26.7)some degree of problems484(39.9)207(40.6)27739.3)high degree of problems438(36.1)199(39.0)23933.9)Narrow spaces? Do you, in your work, experience any problems associated with.< 0.001low degree of problems547(45.1)194(38.0)353(50.1)some degree of problems350(28.8)127(24.9)223(31.7)high degree of problems317(26.1)189(37.1)128(18.2)Organisational and social factors Do you,** in your work**,** experience any problems associated with.Work routines and the distribution of tasks?0.085low degree of problems575(47.4)251(49.2)324(46.0)some degree of problems449(37.0)193(37.8)256(36.4)high degree of problems190(15.7)66(12.9)124(17.6)Collaboration, communication and feedback?0.009low degree of problems620(51.1)279(54.7)341(48.4)some degree of problems419(34.5)175(34.3)244(34.7)high degree of problems175(14.4)56(11.0)119(16.9)Support from your boss/employer?< 0.001low degree of problems790(65.1)363(71.2)427(60.7)some degree of problems274(22.6)101(19.8)173(24.6)high degree of problems150(12.4)46(9.0)104(14.8)Responsibilities, rights and/or expectations?0.008low degree of problems738(60.8)334(65.5)404(57.4)some degree of problems360(29.7)139(27.3)221(31.4)high degree of problems116(9.6)37(7.3)79(11.2)Your possibilities to develop in your work?< 0.001low degree of problems766(63.1)359(70.4)407(57.8)some degree of problems324(26.7)115(22.5)209(29.7)high degree of problems124(10.2)36(7.1)88(12.5)Unreasonable demands?< 0.001low degree of problems692(57.0)327(64.1)365(51.8)some degree of problems352(29.0)134(26.3)218(31.0)high degree of problems170(14.0)49(9.6)121(17.2)Having control and being able to handle the psychological demands that arise?< 0.001**low degree of problems631(52.0)297(58.2)334(47.4)some degree of problems389(32.0)159(31.2)230(32.7)high degree of problems194(16.0)54(10.6)140(19.9)Having no time to take breaks on an ordinary working day?0.012low degree of problems661(54.4)256(50.2)405(57.5)some degree of problems369(30.4)178(34.9)191(27.1)high degree of problems184(15.2)76(14.9)108(15.3)Anxiety about making serious mistakes?0.007low degree of problems773(63.7)326(63.9)447(63.6)some degree of problems288(23.7)136(26.7)152(21.6)high degree of problems152(12.5)48(9.4)104(14.8)Anxiety about not having time to complete your work?0.002low degree of problems579(47.7)237(46.5)342(48.6)some degree of problems393(32.4)190(37.3)203(28.9)high degree of problems241(19.9)83(16.3)158(22.5)Abbreviations: SMET, Structured Multidisciplinary work Evaluation Tool The p-values show the difference between hospital care and nursing home health care workers (HCWs). The p-values represent Chi-square test p-values; bold figures represent p-values < 0.05

Regarding the physical work environment, participants working at hospital care units less often experienced a high degree of problems for the items repetitive movements (p = 0.002), uncomfortable working positions (p = 0.028), and more often a high degree of problems associated with narrow spaces. Regarding organizational and social factors, there were significant differences between participants working at hospital care units and nursing homes for all items, except for the item work routines and the distribution of tasks. Participants working at hospital care units less often experienced a high degree of problems for the items collaboration, communication and feedback (p = 0.009), support from your manager/employer (p < 0.001), responsibilities, rights and/or expectations (p = 0.008), your opportunities to develop in your work (p < 0.001), unreasonable demands (p < 0.001), having control and being able to handle the psychological demands that arise (p < 0.001), having no time to take breaks on an ordinary working day (p < 0.001), anxiety about making serious mistakes (p = 0.007), and anxiety about not having time to complete your work (p = 0.002).

Safety climate

The safety climate mean (SD) NOSACQ-50 scores across seven dimensions ranged from 3.1 (0.6) to 3.6 (0.4); see Table 6. Dimension 3 − management safety justice, dimension 6 − safety communication, learning and trust in co-workers’ safety competence, and dimension 7 − trust in the efficacy of safety system, reached a mean value of 3.5 or higher. There were small but significant differences in dimensions 3, 4, 5, 6 and 7 between participants from hospital care units and nursing homes.Table 6. Safety climate table. Comparison between hospital care and nursing home health care workers (HCWs)Items/questionTotal all HCWsn = 1 214Hospital Care units HCWsn = 510Nursing homes HCWsn = 704P-valueMean(SD)Mean(SD)Mean(SD)NOSACQ-50 ^a^Dimension 1 management safety priority, commitment and competence:3.3(0.5)3.3(0.5)3.3(0.5)0.215^M^Dimension 2 management safety empowerment:3.3(0.5)3.3(0.5)3.3(0.6)0.313^M^Dimension 3 Management safety justice:3.5(0.5)3.5(0.5)3.4(0.6)0.041^M^Dimension 4 Workers’ safety commitment:3.4(0.5)3.4(0.5)3.5(0.6)0.026^M^Dimension 5 Workers safety priority and risk non-acceptance:3.1(0.6)3.2(0.5)3.1(0.6)0.030^M^Dimension 6 safety communication, learning and trust in co-workers’ safety competence3.5(0.5)3.4(0.5)3.5(0.5)0.002^M^Dimension 7 trust in the efficacy of safety system3.6(0.4)3.6(0.4)3.6(0.5)0.008^M^NOSACQ-50 total mean3.4(0.4)3.4(0.4)3.4(0.4)0.837^M^^a^ NOSACQ, Nordic safety climate questionnaire The p-values show the difference between hospital care and nursing home health care workers (HCWs), ^M^ Mann-Whitney U test p-values; bold figures represent p-values < 0.05

Factors associated with perceived level of safety climate

The factor analysis for Safety PHM resulted in three factors or dimensions that together explained 61% of the variance. The dimensions were Safety PHM1 education and guidelines (explaining 41% of variance), Safety PHM2 health and function of patients (explaining 12% of variance), and Safety PHM3 equipment and cooperation (explaining 8% of variance); The factor analysis for selected items of SMET resulted in five factors/dimensions that together explained 60% of the variance. The dimensions were SMET1 organization and cooperation (explaining 34% of variance), SMET2 ergonomics and physical strain (explaining 9% of variance), SMET3 psychological safety (explaining 7% of variance), and SMET4 physical work environment (explaining 5% of variance). The fifth dimension, sitting and eyesight demands (explaining 5% of variance), was considered not relevant to the research question and not included in the regression analysis. All three dimensions derived from the Safety PHM were positively associated with a higher perceived NOSACQ-50 safety climate for PHM (p < 0.001) (Table 7). For all four dimensions derived from the SMET, less problems were associated with a higher perceived NOSACQ-50 safety climate for PHM (p < 0.001–0.005). Furthermore, positive manager support was associated with a higher perceived NOSACQ-50 safety climate for PHM (p < 0.001). The model was adjusted for age in categories.Table 7. Mixed linear regression of the associations between NOSACQ-50 total (dependent variable) and Safety PHM and SMET dimensions (independent variables)Model^a^β (CI 95%)P-valueSafety PHM dimensionsEducation and guideline0.06 (0.04-0.07)<.001Health and function of patients0.10 (0.08-0.11)<.001Equipment and cooperation0.10 (0.08-0.12)<.001SMET dimensionsOrganization and cooperation0.11 (0.10 - 0.13)<.001Ergonomics and physical strain0.02 (0.01 -0.04)0.005Psychological safety0.08 (0.06 - 0.10)<.001Physical work environment0.04 (0.02 -0.06)<.001Positive Manager support*0.21 (0.13- 0.29)<.001Abbreviations: β, regression coefficient; CI 95%, Confidence Interval^a^Model adjusted for all variables in the table, Safety PHM dimensions, SMET dimensions, Positive manager support and age

HCWs’ suggestions for work environment improvements

A total of 878 (72.4%) HCWs provided a response to at least one of the three open-ended questions, of which 615 (70%) gave two or more suggestions. The responses were systematically coded into nine categories, reflecting different areas of suggested work environment improvements regarding PHM. The categories were: (1) knowledge, education and training (n = 267, providing 306 suggestions); (2) communication and collaboration (n = 137, providing 150 suggestions); (3) facilities (n = 134, providing 150 suggestions); (4) routines, safety procedures, and policies (n = 277, providing 326 suggestions); (5) staffing and scheduling (n = 268, providing 307 suggestions); (6) equipment, aids for patient transfer, and ergonomics (n = 280, providing 324 suggestions); (7) ceiling lifts (n = 144, providing 168 suggestions); (8) satisfied with current conditions (n = 62, no suggestions for change); and (9) other work environment improvements (n = 263, providing 292 suggestions). Other work environment improvements included, amongst others, cooperation with other HCPs (occupation therapist, physiotherapist, physician), support from managers, and a general demand for better work conditions. The most frequently mentioned suggestions related to needs for improved staffing, education and training, structured routines, and better access to assistive equipment, particularly ceiling lifts.

Discussion

The findings in this study reveal concurrent high prevalence of MSDs and high self-rated work ability, indicating that presenteeism is common among HCWs in both hospital care units and nursing homes. The need for targeted work environment improvements was further highlighted by the inconsistent and diverse application of safe PHM practices and organizational shortcomings. Differences in PHM procedures, particularly in hospital settings, underscore critical areas for intervention. HCWs proposed a range of measures to promote safer PHM. Key priorities among HCWs in both hospital care units and nursing homes included ensuring adequate staffing levels, rotating physically demanding tasks to reduce strain, improving knowledge with education and practical training and the planning and coordination of patient transfers. Finally, the findings underscore the critical impact of leadership for safe work practices, as positive managerial support was the strongest predictor of high safety climate in relation to PHM.

The findings of this study reveal a complex interplay between work ability, musculoskeletal pain, and work performance. While most participants rated their work ability as good or excellent, musculoskeletal pain was highly prevalent, affecting nearly 94% in the past year, and with almost 80% of participants reporting recent pain during the past seven days. Pain in the neck, lumbar spine, and extremities was common in both care settings. Notably, nursing home HCWs were significantly older and they reported more frequent extremity pain than hospital HCWs, suggesting differences in physical strain related to setting and task characteristics.

Both a higher number of patient transfers and older age has been reported to be associated with an increased risk of work related MSDs among nurses [36].The risk of low back pain has been shown to increase with the frequency of patient transfers [7], which may indicate that physical strain during PHM could be one important contributing factor to the high prevalence of MSDs among HCWs. Previous research has also highlighted MSDs as highly prevalent among HCWs globally and the causes are multifactorial involving aspect of physical, psychosocial, organizational and individual factors [8, 11, 12, 37]. In a study, comparing workers in construction and healthcare, those with higher aerobic capacity and lower body mass index tended to report lower levels of musculoskeletal pain despite being exposed to high occupational physical workloads [38]. The majority of the participants in our study described their work as both mentally and physically demanding. These findings can be related to previous research among HCWs in nursing homes, which demonstrated that low decision authority, poor leadership, high quantitative demands, a fast work pace, and low organizational justice were associated with an increased risk of reporting higher levels of physical exertion [37]. The HCWs, particularly those in nursing homes, also reported other work-related concerns such as headaches, stress, and depressive symptoms. These results are in line with Swedish national data pointing to decreasing mental health in caring occupations [39], and similar trends have been reported in the US, where a high prevalence of depression among healthcare workers has been observed [40]. According to a report published by the Swedish Work Environment Authority, 55% of women in health and social care report excessive workload and limited opportunities for recovery [39].

Nearly one-third of the participants in our study reported taking sick leave exceeding eight days in the past year. Additionally, almost half of participants reported health problems during the previous week but still chose to work. Although nursing home HCWs more frequently reported working despite health problems compared to hospital HCWs, no significant differences were found between settings regarding overall sick leave or presenteeism. This pattern suggests that working despite pain may be a normalized behaviour across settings, embedded within workplace culture, as demonstrated in previous research [41]. While presenteeism may reflect commitment or perceived necessity, its potential impact on performance, injury risk, and patient safety warrants attention. Presenteeism has been linked to HCWs’ sense of duty and consideration for colleagues and managers, and is often driven by high levels of commitment [42]. It is also associated with impaired performance, higher injury risk, and compromised patient safety, as well as broader impacts on health, well-being, and economic outcomes [43]. A study by Dahini et al. [44] shows that lower levels of presenteeism are linked to favourable organizational factors, specifically, high leadership ratings and adequate staffing resources. Variations in PHM procedures, especially within hospital settings, highlight key areas where improvements are needed. In response, HCWs in this study proposed a range of measures to promote safer PHM. Key priorities included ensuring adequate staffing levels, rotating physically demanding tasks to reduce strain, and improving the planning and coordination of patient transfers. Organizational and situational factors have previously been shown to significantly influence the increased use of assistive devices, with care situations playing a particularly critical role in nursing homes [45]. In this study, even though PHM tasks were performed frequently, often multiple times per shift, many participants reported conducting transfers without assistive devices, and collaborative handling was less common in hospital settings compared to nursing homes. In line with these quantitative findings, the open-ended responses further highlighted that the availability and use of assistive devices were considered key priorities among HCWs in both hospital care units and nursing homes. The availability of equipment and ceiling lifts, along with supervisor encouragement and annual training, have previously all been associated with higher utilization of safe PHM equipment [9]. Previous research shows that the use of motorized assistive devices significantly reduces work-related MSDs [46]. Moreover, the safest methods for patient handling involve the use of floor or ceiling lifts, as well as air-assisted devices for lateral transfers and repositioning tasks [10, 15]. The presence of organizational shortcomings, lack off staff and increasing workload hinders the consistent application of safe practices using assistive devices [47, 48]. In the present study, organizational shortcomings were particularly evident in hospital settings. Staff reported an absence of formal work environment policies, established routines, and regular PHM training. Although systematic patient assessments of mobility and health prior to transfers are endorsed in the scientific literature and in Swedish guidelines and regulatory frameworks [17, 19], they were infrequently performed in our study. The findings in the current study suggest possible weaknesses in local safety climate, especially in relation to leadership, procedural clarity, and opportunities for competence development for improving PHM. Addressing these gaps through multifactorial workplace interventions with clear guidelines, available equipment, and annual training, along with supervisor encouragement is essential to promote safe PHM practices [8, 9, 14]. Lee et al. [16] found that organizations actively fostering a positive safety climate, implementing ergonomic measures, and cultivating a people-oriented culture achieved significantly better outcomes. These included lower physical workload and job strain, increased job satisfaction, reduced risk perception, and fewer reports of work-related injuries and symptoms.

The regression model in our study identified several factors significantly associated with a higher perceived safety climate in relation to PHM. These included education and access to guidelines, systematic assessment of patients’ health and functional abilities, appropriate equipment, staff collaboration, organizational and managerial support, ergonomic practices, psychological safety, and the physical work environment. Among these, positive managerial support emerged as the factor with the highest loading, highlighting the pivotal role of leadership in shaping safety perceptions within healthcare environments. Consistent with the present findings, previous studies have also reported that HCWs rated their safety climate positively, with leadership quality and job satisfaction identified as key contributing factors [49, 50]. Further research is needed in the healthcare settings to deepen the understanding of how safety climate can be strengthened in relation to PHM.

Strengths and limitations

A strength of this study was the large number of participating HCWs from both hospital care units and municipal nursing homes across different regions in Sweden, which enhances the generalizability of the findings. Given that the challenges faced by HCWs are similar across many Western countries, the insights gained may be transferable to comparable settings internationally. The included healthcare units were participants in a cluster randomized trial [20], which may indicate a selection bias towards healthcare units interested in PHM and safety climate. Validated self-reported outcome measures were used. Using the NOSACQ-50 to compare safety climate between hospital healthcare units and nursing homes revealed only minor differences. These results needs to be further explored with inclusion of additional factors such as age, years of employment at the current workplace and staffing levels. HCWs completed the questionnaire through a secure web-based platform which enabled easy access for the responders. A strength of the study was the use of both qualitative and quantitative data where the open-ended questions confirmed the overall findings and also added new information providing a more in-depth and concrete understanding of the results. Varying degree of HCWs exposure to PHM tasks may have influenced the findings. Future studies could benefit from focusing specifically on those HCWs most directly engaged in these work tasks. The survey was in Swedish, which may have excluded participants with limited language skills in Swedish. To explore factors associated with the perceived level of safety climate, factor analyses were initially performed on the Safety PHM and SMET questionnaires. This approach was used to reduce the number of variables in the regression model and to avoid multicollinearity. All identified dimensions demonstrated significant associations with the perceived safety climate in the regression analysis. However, the contribution of individual items within these dimensions was not assessed, which may limit the precision of the findings. Moreover, as the identified dimensions were derived from the present sample, their applicability to other healthcare settings should be interpreted with caution.

Conclusions

Healthcare workers (HCWs) in both hospital care units and nursing homes reported a paradoxical status, with a high prevalence of MSDs coexisting with high self-rated work ability. Despite frequent task of patient handling and movement (PHM), adherence to safe PHM practices was inconsistent, particularly in hospital settings where organizational shortcomings such as lack of guidelines, insufficient training, and limited use of assistive devices were more evident. Across both settings, HCWs emphasized the importance of adequate staffing, task rotation, improved training, and access to appropriate equipment to reduce strain and improve safety. The HCWs suggestions on work environmental improvements underscore the importance of multifactorial, organizational-level interventions, emphasizing leadership engagement, structured training approaches and context-specific solutions. Addressing these areas is critical to improving healthcare workers’ occupational safety and health in relation to PHM.

Supplementary Information

Supplementary material 1.

Supplementary material 2.