Using an intervention mapping approach to develop prevention and rehabilitation strategies for musculoskeletal pain among surgeons

A systematic literature search with a scoping approach was performed as part of the Intervention Mapping methodology [30]. In accordance with the scoping approach the systematic literature search was conducted in order to obtain in depth knowledge of any potential problems and challenges surgeons may present with. The knowledge was used to compose the semi-structured interview guide. The databases PubMed, Embase and CINAHL were searched until 17 April 2017 using the following search strategy adjusted to fit each database criteria: (surgeon*) AND (occupational exposure OR work-related exposure OR job-exposure OR job demands OR workload OR work-related) AND (musculoskeletal disorders OR musculoskeletal diseases OR musculoskeletal pain OR occupational diseases OR work-related diseases). Articles were selected based on 1) title, 2) abstract, and 3) full text. The systematic literature search was conducted by author AH and continuously discussed with author LNA and author TD.

Semi-structured interviews were conducted face-to-face with surgeons to understand the surgeon’s type of job, its influence on health, and their experiences with health initiatives. Based on the literature search, a semi-structured interview guide was designed. It evaluated the issues of the surgeons’ workplace, their experiences with pain, approach to their health, and their experiences with health initiatives as well as their experiences of challenges concerning such health initiatives. Interview questions were formulated in everyday language and were preceded by descriptive questions to enhance confidence and familiarity between the interviewed surgeon and the interviewer. The semi-structured interview guide was discussed between co-authors before conducting the interviews. Only the interviewer (author AH) and the participant were present during the interview.

Interviews were conducted in Danish, audio-recorded and transcribed verbatim by author AH. Participants were subsequently asked to confirm the accuracy of the content. The quotations used in the present paper were translated from Danish to English by a professional translator.

The analyses were based on systematic text condensation, which is a descriptive and explorative method used for thematic cross-case analysis [31]. It is a four-step process derived from theories of phenomenology and supports the surgeons’ experiences being expressed in their own words.

Recruitment for the interview was done by author TD and an established contact person at two medical wards (Gastrointestinal and Gynaecology and Obstetrics) at two distinct hospitals. Recruitment was based on earlier contact and therefore convenience sampling was used. Surgeons interested in participation were sent written information and ensured complete anonymity. All interested surgeons agreed to participate.

Results from the literature search and semi-structured interviews will be presented to enable a detailed description of determinants that influence musculoskeletal pain among surgeons. It was on the basis of these results that the logic model of the problem was developed, and the overall goal was formulated.

The systematic literature search initially identified 179 articles (Pubmed: 71, Embase: 95, CINAHL: 13). Based on the review procedure 14 articles were considered relevant. Among the relevant articles was one systematic review [32] including 35 studies about the prevalence of musculoskeletal pain among surgeons performing minimally invasive surgery. All types of study design were searched. Except for the systematic review only studies with quantitative methodology were identified. The literature search supported that work-related musculoskeletal pain is a common and documented problem among surgeons [5, 33, 34]. Surgeons have long workdays and a physically demanding job. They are exposed to cumulative awkward postures, repetitive movement, and strenuous exertion during the performance of surgery, which may lead to muscular strain and ultimately the development of musculoskeletal pain [6, 18]. A systematic literature review from 2017 included 35 studies and found a prevalence of musculoskeletal pain among surgeons varying between 73 to 88% [32]. A prevalence well above that in the general working population [7]. The most prevalent painful body regions were the neck and the lower back [14, 18, 20, 34]. Studies report that surgeons believe their surgical performance is affected by pain [5, 20], and that surgeons do not pay attention to their own health during surgery [12, 13]. In a study by Park et al., 40% of the surgeons reported to disregard their physical complaints [15]. Another study showed that 36% of the surgeons reported to work in spite of pain, as they considered pain to be part of the job [14]. In addition, many surgeons reported to be unaware of physical ergonomic guidelines relevant to the operating theatre [16, 17].

Six surgeons from two Danish hospitals volunteered to participate in the present study. They were interviewed at their workplace in an undisturbed setting and with a duration of 52–78 min. All the surgeons were experienced and had worked as surgeons for six to 20 years. Weekly working hours were reported to be between 45 and 60 h. Musculoskeletal pain was present for four out of six surgeons. Characteristics for the six surgeons are shown in Table 1 (study participants’ names are pseudonyms).

We applied systematic text condensation to identify themes in the interviews [31]. The analysis identified four main themes derived from the data: (1) Experienced challenges; (2) Surgeons do not complain; (3) Taking responsibility; (4) How to handle it. Additionally, three subthemes were identified under the fourth theme: (a) work-related focus on physical ergonomics, (b) Micro-breaks and physical activity and (c) Experiences with health promotion initiatives. In the following, the results from the interviews are presented.

“I suffer from chronic neck pain ( … ) Can that be recognised as a work-related injury? It is a work-related injury, I think. It’s not like I have other things that affect my neck in that way ( … ) I don’t know about the future. You wonder what it will mean when you get older, after 15- or 20-years work, if I already have pain in my neck now.” (Andreas)

Lengthy operation times and strenuous work postures for many hours, are a particular burden for the surgeons. Several of the surgeons had witness that colleagues had been forced to stop their career as a surgeon or to change the work they perform:

“One of my colleagues who is a professor, has pretty much stopped operating. His back simply gave him so much pain that he was beside himself, so now he is mostly professor and manager, but it’s a waste of a surgeon, for he is extremely able.” (Susanne)

“Surgeons are not the type of people who go and complain ( … ) no one has the least idea that I have a piriformis syndrome. I’ve never mentioned it, or maybe there was a day if I could hardly walk. But it’s not something you talk about, though everyone is affected by work postures.” (Martin)

The surgeons did not share concerns with colleagues about their work-related musculoskeletal pain. It is as if there is a mutual acceptance about musculoskeletal pain being a natural consequence of their work.

“There’s no doubt that, if you’re going to be in a surgical environment, you have to have a particular temperament ( … ) those who don’t have it, have a hard time ( … ) it’s like this: I’m damned well not going to be the one who can’t cope with it.” (Susanne)

From a long-term perspective, the surgeons are conscious of the fact that musculoskeletal pain may challenge their chance of maintaining their job.

“Once I have said that I will operate on her, I can’t simply walk away from her, I mean, I can’t let the patient lie there ( … ). It’s a human being, you can’t let them lie there, she’s been put to sleep, I mean her stomach’s open?” (Susanne)

Feelings of responsibility for patients were expressed by several of the surgeons interviewed. This prohibited the surgeon from stopping or taking a break. On the other hand, one surgeon mentioned that she was also conscious about the responsibility to herself. She was obliged to consider whether she should call another surgeon if she was not capable of continuing herself, for example if tiredness was affecting her ability to perform the operation safely. This balance may be difficult, and it was also described by Pia:

“I also feel a bit that it’s my responsibility to make sure that I don’t work so many hours that I can’t manage in reality to look after my body ( … ) then you have to fight to overcome that pressure that you have to work a lot all the time, and it is a bit so that I can stay comfortable with myself and in good shape.” (Pia)

It is the surgeons themselves who carry the responsibility of balancing these challenges and making decisions both about the short-term (if they need a break) and about the long term (to improve their physical capacity by doing physical exercise training). In most cases, the surgeons do not tend to give their own health the highest priority. This is evident when they describe their culture as “Tarzan-like”. The surgeons perform operations even if it negatively affects their health:

“I know plenty of colleagues who stands operating with tearing, burning pain down one leg or who have to take painkillers just to be able to be there at all.” (David)

Painkillers are used as a quick short-term solution, providing the surgeons with the ability to do their job and take responsibility for the patients.

“When Mogens comes back looking like a broken number 7, I’m perfectly aware that it’s his back hurting him. It’s not that difficult to work out. Then he just takes a couple of ibuprofens, and we keep rolling, don’t we?” (Christian)

One surgeon mentioned that a representative for the clinic of occupational medicine once visited the operation theatre. It was, however, unclear whether this was an initiative from the management or what, and the surgeon felt that the initiative lacked connection to his daily routines:

“A man came from the clinic for occupational medicine to look at how we stood during the operations, and he had no difficulty in seeing that it was a problem, but apart from that nothing happened ( … ) He just took a look and took pictures to provide documentation of the way we stood and for how long, but it was as though that was the end of it.” (Andreas)

Some of the surgeons explained that they felt uncertain because they lacked the knowledge on how to adjust the available equipment and their workplace layout as well as other potentially beneficial initiatives.

“We just don’t know how best to use it ( … ). In reality, we should have someone or other who knows about it who can tell us: This is how the chair should be positioned every time.” (Martin)

The surgeons were aware of the importance of correct work posture but were insecure how to deal with it. One surgeon described how he had consulted a physiotherapist regarding his own work posture:

“So I paid out of my own pocket, in fact, to get an occupational trial assessment at a physiotherapist’s, and then we play-acted an operation game, and then she told me off about how I ought to stand, and yes, there probably was a difference between how I stood and how I should have been standing, and then she devised a specially created back exercise programme, which I had to admit did help.” (Christian)

One surgeon explained that she was aware that there was the opportunity to ease the workload during operations. It was, however, a problem for her to take advantage of it. For example, when something hurt during an operation:

“If you’re involved in lengthy operations, to make it less physically demanding you can take occasional breaks, and that’s something we really ought to do more ( … ) but people don’t do it ( … ) I don’t think there has been much of a focus on it, I mean the idea of taking breaks, here on this ward – unfortunately.” (Pia)

The surgeons demonstrated some knowledge of possible solutions. One solution, for example, was to break up their work-load. However, the surgeons did not make use of this opportunity during their work day, and nor did they indicate any collective understanding or regulations for breaks.

At the same time, the surgeons were aware that their physical capacity could increase their work ability and prevent musculoskeletal pain. Some of the surgeons described running or biking in their leisure time to become physically fit as a preparation for their job as surgeon:

“I can feel that doing some training away from work – that helps! ( … ) you can’t manage without it. Previously I didn’t need to keep in form to prevent neck, shoulder, legs and sciatica and all sorts – it’s started to creep up, so I am forced to keep myself in form, for otherwise I have a bad something or other.” (Martin)

The surgeons expressed thoughts and considerations as to different potential health promoting initiatives e.g. exercises with resistance bands:

“We had a theme day a few years ago, where some people came and showed us some resistance bands we were supposed to stand and pull, some classic stuff for secretaries, and I can’t stand it. I’m sorry. It’s just not for me ( … ) I think it’s ridiculous! Then rather play half an hour of table tennis and have fun doing that.” (David)

The lack of motivation for activities with resistance bands expressed by this surgeon may be explained by the fact that he had not experienced musculoskeletal pain related to his work. When asked, he reflected that he might be more motivated to take up this kind of preventive initiative if he had musculoskeletal problems.

As described earlier, the surgeons consider musculoskeletal pain a private matter, and one of the surgeons underlined this by rejecting the idea of conducting physical exercise training at work:

“I mean, I am here for the sake of the patients, and I am here because I am paid to carry out that job. I do not get paid for having to go down and be in a training centre to lift weights, that is not why I am here, that’s something I do in my leisure time.” (Susanne)

Even though surgeons may be negative about doing physical exercise training during working hours, it is crucial that the management genuinely support and prioritise surgeons’ health.

“All well and good that management have been given a check - they have now made the health-promoting initiatives - but one pretty important thing is missing, namely that when you get home after a day’s work, that time is actually prioritised in our everyday work for it. And it isn’t, because we’re told 'that’s something you can do when you have time” (Christian)

Providing the time for surgeons to carry out health promotion initiatives as part of maintaining their work ability is essential for success.