Stress and sleepless nights bring pain

Wellness includes work organization

Your hospital may be causing your workers pain – and not just for the reasons you think. Job stress, including harassment from coworkers or unsupportive supervisors, contributes to musculoskeletal pain and injury and a host of other problems, according to a growing body of research.

As employers promote wellness for their workers, they should look at workplace factors that create stress and can lead to other ailments, says Paula Grubb, PhD, a research psychologist with the Division of Applied Research and Technology at the National Institute for Occupational Safety and Health in Cincinnati. "Teaching time management and relaxation doesn't help with organizational issues."

Twelve-hour shifts, which increase the risk of injury, may be unavoidable, but staffing, communication, training and supervisory support can be improved, she says.

Psychosocial problems can lead directly to physical ones. For example, one study found that long-term care workers got about a half-hour less sleep each night and had twice the risk of cardiovascular problems if their supervisors were less supportive of work-family issues.1

In fact, sleep deficiency is "a sentinel measure of problems in the workplace," says Orfeu M. Buxton, PhD, neuroscientist and assistant professor in the division of sleep medicine at Harvard Medical School.

"A workplace that has a lot of conflict might increase insomnia symptoms," he says. "A workplace that's too rigid or inflexible may decrease sleep duration." Harassment, such as bullying, has a similar effect, he says.

Fatigue has become a major concern in health care because of threats to both worker safety and patient safety — through an increase in medical errors, injuries and chronic conditions such as obesity. (See related article in HEH, September 2012, p. 105.)

Three-quarters work with pain

Pain is a common plight of health care workers. Stress in the workplace makes it worse.

In a survey of almost 1,600 health care workers in two major medical centers in the Boston area, 73% reported pain in the past three months. A third of them reported pain that was severe enough to interfere with their work.2

Nurses with a supportive supervisor, a higher status job title and safe patient handling practices were less likely to have sleep deficiency. Workplace problems, such as verbal harassment, increased sleep deficiency and pain.

While it might seem obvious that pain could cause sleep problems, research shows the reverse connection, as well, says Buxton. "The extent to which sleep deficiency is leading to pain is perhaps underappreciated," he says.

"If you restrict sleep or deprive people of sleep in the lab, they have more spontaneous pain. A controlled pain stimulus is sensed as more severe," he says. "If you have insomnia, pain sensing is also worsened."

Other psychosocial issues may be related to pain among health care workers. In an eight-year prospective study at the University of Utah in Salt Lake City, people who had greater levels of depression and anxiety in baseline tests were more likely to report back pain years later.

"Data are increasingly robust that job factors, personal factors and psychosocial factors contribute to the risk of injury. True prevention programs will have to address all of these," says Kurt Hegmann, MD, MPH, professor and director of the Rocky Mountain Center for Occupational and Environmental Health, a National Institute for Occupational Safety and Health Education Research Center. Hegmann is also editor-in-chief of the occupational medicine practice guidelines for the American College of Occupational and Environmental Medicine.

Pain linked to medical errors

A detailed survey of 1,171 nurses in North Carolina showed how the worker and patient safety problems are inter-related: High rates of pain and depression, impaired productivity and increased medical errors.

More than two-thirds (71%) of the nurses reported working with pain; 18% reported depression. A majority of them also indicated that health problems had affected their productivity. "Presenteeism," or lower productivity due to physical or emotional health problems, was associated with an increase in patient falls and medical errors and a decrease in the self-reported quality of care.3

"Our findings indicate that musculoskeletal pain and depression are among the major causes of nurses' presenteeism," the authors said. "Our findings also support research that has identified pain and depression as significant contributors to decreased work productivity."

Programs that address stress management as well as organizational factors provide the best opportunity to make an impact and improve worker health, says Buxton. "You intervene at the individual level with information, resources and tools, but you also intervene at the unit level to change workplace practices," he says.

The patient safety link may help you get support to make the changes, says Grubb.


1. Berkman LF, Buxton O, Ertel K. Managers' practices related to work-family balance predict employee cardiovascular risk and sleep duration in extended care settings. Jrl Occ Health Psych 2010;15:316–329.

2. Buxton OM, Hopcia K, Sembajwe G, et al. Relationship of sleep deficiency to perceived pain and functional limitations in hospital patient care workers. JOEM 2012;54:851-858.

3. Letvak SA, Ruhm CJ, Gupta SN. Nurses' presenteeism and its effects on self-reported quality of care and costs. AJN 2012;112:30-38.